1. Ethical Challenges of Healthcare Reform
Laurence B. McCullough, Ph.D.
Dalton Tomlin Chair in Medical Ethics and Health Policy
Center for Medical Ethics and Health Policy
Baylor College of Medicine
Houston, Texas

2. Healthcare System or Gemish?
A system is a clear, consistent, coherent, centrally led and managed service or production process
We do not have a healthcare system in the United States
We have a healthcare gemish
Private and public providers and payers; secular and sectarian providers; federal and state regulation
There are systems within the gemish: VHA, Medical Corps of armed services, Indian Health Service, Hospital Districts in Texas
No one individual is in charge; no “CEO” of US healthcare
Healthcare professionals and organizational leaders have always been in charge of patient care and will still be under heathcare reform

3. Professional Integrity
Lead change the way it always occurs in our democracy, from below
On the basis of professional integrity, a professional virtue that governs in all healthcare settings, systems and gemishes alike
Professional integrity
Practice medicine, conduct research, and teach to standards of intellectual and moral excellence
Intellectual excellence: Submit all clinical judgment, decision making, behavior, and organizational policies and practices to the discipline of evidence-based reasoning
Moral excellence: Commit to the protection and promotion of the patient’s health-related interests as one’s primary concern and motivation, keeping individual and guild self-interest systematically secondary
Gregory J 1772; Percival T 1803
Healthcare professionals have an obligation, based on professional integrity, to provide quality healthcare

4. Integrity-Based Improvement of Patient Care
Poor quality healthcare: Unmanaged and therefore uncontrolled variation in the processes of patient care, resulting in (a) unmanaged and therefore preventable mortality, morbidity, lost functional status, and unnecessary pain, distress, and suffering and (b) unmanaged costs
Provision of poor quality healthcare is inconsistent with professional integrity
Intellectual excellence is violated by non-deliberative clinical judgment and practice that results in unmanaged variation
Moral excellence is violated by (a) preventable mortality, morbidity, lost functional status, and unnecessary pain, distress, and suffering and (b) professionally irresponsible use of resources
Provision of poor quality healthcare is economically wasteful, which is socially irresponsible

5. Integrity-Based Improvement of Patient Care
Quality healthcare: Responsibly manage variation in the processes of patient care, aiming to improve outcomes
Identify components of the process of patient care
Identify components that do not affect outcome and eliminate them
Incrementally improve components that do affect outcome, alert to risk of making things worse, especially in complex processes of patient care
Patients’ preferences will be (steeply) discounted
Quality healthcare is primarily a beneficence-based, not autonomy-based concept

6. Integrity-Based Improvement of Patient Care
Result of integrity-based improvement of patient care: The healthiest possible patient
Primary, secondary, and tertiary prevention
The healthiest possible patient is the least expensive patient
Integrity-based improvement of patient care is the means to responsibly manage the cost of healthcare
Keep the horse (quality) in front of the cart (cost)

7. Integrity-Based Improvement of Patient Care
Improved quality of patient care will prevent unacceptable opportunity costs
An unacceptable opportunity cost occurs when clinicians use a clinically non-beneficial resource for a patient and that use blocks access to the resource for another patient who could clinically benefit from the use of that resource
A major problem in responsible use of critical care beds, e.g., patient with multi-organ system failure on full code status

8. Integrity-Based Improvement of Patient Care
Improved quality of care will also prevent rationing
Rationing: Denial of access to process of patient care that is reliably expected, i.e., supported in evidence-based reasoning, to be clinically beneficial
Rationing is not permissible in integrity-based clinical practice and organizational policy
Denying access to clinical management that does not meet “modicum of benefit” test is not rationing
Doing less than has been done in the past is not rationing
Incentivizing use of less expensive but equivalently effective clinical management is not rationing
Healthcare professionals and organizational leaders should openly refuse to cooperate with organizational or health policies that result in rationing, because rationing is destructive of professional integrity and therefore destructive of organizational culture of professional integrity

9. Response to Era of Accountable Care Organizations
Accountable care organizations (ACOs)
“…ACOs are best understood as affiliations of health care providers that are held jointly accountable for achieving improvements in the quality of care and reductions in spending.”
Greaney TL 2011

10. Response to Era of Accountable Care Organizations
Creating ACOs will not eliminate the healthcare gemish
Physicians, other healthcare professionals, and healthcare organizations already have ethical obligation, originating in the eighteenth century, that should guide the development and leadership of ACOs: To become and remain accountable for the quality of patient care
John Gregory ( ) called for accountability of physicians to scientifically sophisticated laypersons for the quality of patient care
Gregory J 1772
Thomas Percival ( ) called for accountability of physicians and surgeons to each other for the quality of patient care
Percival T 1803
Percival also called for leadership of healthcare organizations to be accountable to the ethics of clinical practice, with professional responsibility disciplining economic concerns of healthcare organizations
ACOs should be based on these long-established, ethically justified forms of accountability

11. References
Greaney TL. Accountable care organizations – the fork in the road. New Engl J Med 2011 Jan 6;364(1):e1. Epub 2010 Dec 22.
Gregory J. Lectures on the Duties and Qualifications of a Physician. London: W. Strahan and T. Cadell, In McCullough LB, ed. John Gregory’s Writings on Medical Ethics and Philosophy of Medicine. Dordrecht, Netherlands: Kluwer Academic Publishers, 1998:
Percival T. Medical Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons. London: Johnson & Bickerstaff, 1803.

12. Ethical Challenges of Healthcare Reform
Laurence B. McCullough, Ph.D.
Dalton Tomlin Chair in Medical Ethics and Health Policy
Center for Medical Ethics and Health Policy
Baylor College of Medicine
Houston, Texas