Quality Assessment of Ethics in Health Care: The Acccountability Revolution

Formal quality assessment and direct public accountability for quality are hallmarks of what has been called the "third revolution" in health care. Given the prominence of quality assessment and improvement initiatives in medicine, it is starting that there has been near silence on the possibility of applying quality assessment techniques to ethics practices within health care organizations. Quality assessment of ethics might take three forms: evaluating the ethical behavior of health professionals; the ethics policies and mechanisms embraced by the organization; and, as a subset of the latter, the particular competence of ethics committees or consultants advising on contested cases. Thus, patient-consumers choosing a health care organization or plan may first want to know whether they can expect the physicians to be conversant with current thinking about ethics, to respect patients' autonomy by sharing adequate information and supporting patient decision making, to honor patients' wishes to forgo unwanted life-sustaining treatments, and to protect the confidentiality of patient information. Second, they may want to know whether the health care organization or plan has written policies on problems such as assessing patients' decisional capacity, forgoing life-sustaining treatment, honoring patients' advance directives. Third, they may ask whether the organization or plan has a mechanism for obtaining advice on ethically difficult cases, and whether that mechanism (be it a committee, an ethics consultant, or something else) is competent, as well as open and accountable to patients. This article explores the potential of quality assessment, as an instrument of direct public accountability, to transform clinical ethics. Patients' rights and health care professionals' duties have been passionately championed by modern bioethics for the last quarter-century. But patients and consumers themselves have yet to assert real influence over the kind of ethical practices they encounter. Quality assessment has the potential to become a way of their doing so. If quality assessment tools are to be used to assess medical practice and health care organizations, patients have a stake in making sure that those tools assess not just technical medical care, but ethical behavior as well. This article is an argument for including ethics in the accountability revolution. Ethics should be more than rhetoric, however passionately declaimed; it should be behavior that is assessed and promoted. This means using quality assessment techniques to evaluate ethical behavior within health care organizations. The article begins by analyzing the ascendancy of quality assessment as a mechanism of accountability. It then analyzes what role quality might play in assuring public accountability in ethics. The author traces the development of empirical work in ethics to suggest the feasibility of quality assessment. The article then considers pitfalls and limitations, including potential misuse in law of quality assessment data on ethics. Finally, the article shows the potential for quality assessment to perform a kind of technology-forcing function in bioethics. It can force organizations and professionals to make good on the rhetoric of patients' authority to decide, while narrowing the gap between ethics proclamations and clinical practice, and propelling the development of organizational ethics. The assessment and accountability revolution thus has the potential to transform bioethics itself.