Ethics committees and cost containment.

Health care institutions are under strong pressures to contain costs. Should ethics committees within those institutions assist in such efforts? If not, can ethics and economics be separated that neatly? The complexity of this issue derives in part from the large array of cost containment activities available to health care institutions. In a broad sense, all institutional efforts to deliver services more efficiently can be understood as cost containment efforts, from changing to lower cost suppliers of linens or medications to streamlining billing procedures. However, decisions to adopt such measures would normally have no direct or significant impact on patient care and are more appropriately wed as managerial, rather than strictly ethical decisions. Consequently, they would not be brought to the attention of an ethics committee. But the line between management decisions and those that are strictly ethical is often not clear. For example, managerial and ethical issues are intertwined when a decision is made to reduce nursing staff coverage in an ICU, for this could well have a significant adverse impact on patient care. It is the potential for affecting patient care that gives management decisions an ethical impact and that might make those decisions a proper concern of an ethics committee. Even though restricted in this way, a wide range of cost containment practices and policies with implications for patient care remains. What are some examples? A hospital may seek to develop means for speeding the discharge of Medicare patients for whom it receives a fixed reimbursement under the DRG system. Or it may develop a policy to deal with patients who have overstayed their welcome by remaining beyond the number of days for which Medicare will reimburse the hospital. Whether to expand a consistently overburdened ICU is an institutional capital expenditure planning decision fraught with life or death consequences for future patients. Moreover, a policy setting standards for admission of individual patients to the ICU will have a direct impact on identifiable patients accepted or refused admission under that policy. Whether to close money-losing emergency departments or clinics that largely serve indigent or Medicaid patients are policy decisions that will seriously affect the access of such patients to health care. These are all decisions that affect patient care and raise serious ethical concerns. Yet ethics committees usually lack decision-making authority in any of these matters and typically play a limited advisory role at others' request. Moreover, it would be highly unusual for hospital management to involve an ethics committee in most of these policy and planning decisions. What then are the arguments for ethics committee involvement in cost containment decisions-, The fundamental point in support of involvement is that many policy decisions have significant ethical implications and therefore seem within the mandate of ethics committees. An ethics committee may sometimes reasonably believe that it will be the most effective, or even the only, spokesperson for patient interests and for the ethical responsibilities of the institution in such decisions. If the ethical aspects of these cost containment decisions are to receive due consideration, it is sometimes the ethics committee that must press diem. Further, an important factor affecting the ethical acceptability of most cost containment measures is the process by which those measures are adopted-that process should be public, allowing input from all affected parties so as to increase policymakers' accountability for their decisions. Consideration by the ethics committee can help ensure that difficult and controversial ethical issues raised by some cost containment efforts are more fully and publicly aired, thereby increasing the overall legitimacy of the decision process. Finally, the ethics committee may reasonably expect that its involvement in cost containment decisions will result at least in some instances, in ethically sounder decisions and policies. …