Is there an ethics deficit in the delivery of healthcare?

Ethics of quality in Healthcare Delivery

Is there is an ethics deficit in the delivery of healthcare?

Ethics are paramount in clinical research. Currently there is emerging requirement for ethical values and oversight of quality improvement projects. However, it seems unclear if strong ethical principles underpin the delivery of routine healthcare. By routine delivery of healthcare I mean activities such as scheduling/rescheduling appointments, communication methods when non-clinical staff are dealing with patients, staffing levels (numbers, skill mix, acuity matching,etc) and similar. I also mean most of strategy, planning and operations at the provider level.

It is well recognised that it is the huge variation in processes of care delivery results in large disparities in healthcare outcomes. I subscribe to the view that it is not the science or the individual that causes bad results; it is the vagaries of the processes of care delivery that causes poor outcomes.

Policy making is subject to ethical ideas that are broadly utilitarian. Individuals are also subject to ethical principles. Ethics for healthcare professionals especially doctors are specifically person centric irrespective of whether they are individual professionals or patients. Between policy and individuals lies the system, group or team, whose operations are not in reality tested against ethical principles. There seems no clear group based ethics on which care can be delivered though there are innumerable rule based arrangements that seem not to satisfy the cause of quality in healthcare delivery.

In other words, individuals are held to account for quality deficits using ethical principles- groups and systems are not. A group of individuals who practise sound ethical principles do not constitute a ‘group ethic’. The lack of group ethics seems to be preventing known good outcomes from being achieved.

How can this quality gap due to the variation of processes and outcomes be assigned with relevant ethical principles or frameworks with a view to resolving them?

My main argument would be that it is unethical not to aim to achieve or not to achieve a desired result:

-          in the absence of any material restricting factors and

-          when the knowledge and methods have been described and publicly available

However, since medical ethics is effectively applicable to individuals and other ethical theories are applicable to policy making, there seems either a lack of ethical theory/reasoning or a lack of application of ethical theories to understand the ethicality of group operations in healthcare delivery.

My assumption is when the issue of ethics for operational groups who are implementing care delivery are defined, available and clarified a contextual framework could become available to bridge the quality delivery gap where healthcare delivery outcome deficits can be seen as ethical deficits; thus ethics becoming a powerful lever in ensuring highest known optimum outcomes.

The utilitarian policy making at one end, with medical ethics (a mixed application of various basic principles) at the other end, seems not be served very well by the current version of possibly deontological 'operations'. Is that the case? If that was the case, how do we resolve it?

©M HEMADRI

Follow me on Twitter @HemadriTweets

CLINICAL WRONGOLOGY

CLINICAL WRONGOLOGY©

M. HEMADRI

Substantial activity in clinical medicine is not performed on the basis of clear unequivocal evidence

Substantial activity in clinical medicine cannot after care delivery find evidence to back it

Substantial clinical care is delivered incompletely

Substantial amount of errors are found in the delivery of care

Substantial numbers of clinicians are either unable or unwilling to accept the above

In effect there is plenty or wrongness in theory, plenty of wrongness in practice and blindness to wrongness in clinical medicine. The wrongness is affecting patients by causing poor experience of healthcare, avoidable complications and avoidable deaths. Clinical wrongness is also affecting doctors and other clinicians causing variations in practice, restriction in the ability to practice appropriately and punishments for poor clinical performance.

There will be a day in the future when clinical medicine will practiced on the basis of proven science. We will truly rejoice on that day. Till that day arrives clinicians will need an approach that will help in appreciating, understanding and coping with the wrongness that is prevalent. The study of that approach is Clinical Wrongology.

Clinical Wrongology will remove the blindness to wrongness. It will make clinicians appreciate that there is wrong, wrongness and errors everywhere and these are normal to general life and clinicians are not exempt from this. Clinical wrongology will then encourage clinicians to cope with the wrongness around them and will show some methods to practice within the wrongness atmosphere with a view to increasing safety, quality and decreasing cost.
  
Clinical  Wrongology, the new specialty in healthcare is now declared open.

Watch this blog as there will be more on this subject.

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: While there are philosophers who are masters on the subject of wrongness and great experts in the study of error, my inspiration for thinking about wrongology and clinical wrongology was from 'Being Wrong', Kathryn Schulz's brilliant book. Kathryn if you are reading this blog I hope you do not mind me calling myself a Clinical Wrongologist, (perhaps the worlds first and only one till date); having vainly given myself that title I could be motivated to live up to it; unless I am totally wrong on that!

NB: Persons in healthcare who want to be involved and contribute to this effort, please leave a comment with a means of contacting you or send a direct message to me on twitter.