Moral Judgments in the Rationing of Health Care ...

Moral Judgments in the Rationing of Health Care Resources: A Comparative Study of Clinical Health Professionals Larry W. Foster, PhD Linda J. McLellan, MSW

ABSTRACT. Social workers, physicians, and nurses from a major urban teaching hospital were assessed and compared regarding their attitudes toward the rationing of health care. Responscs to eighteen statements of considered moral judgments in the rationing of health care resources were analyzed in terms of levels of agreement with each. A11 three professional groups rejected rationing based on patient age and socioeconomic worth. However, social workers and physicians were more likely than nurses to consider such factors as cost-bencfit ratios, quality of life, relative strength of a patient's moral claim, and scarcity of resources in rationing decisions. Study findings appcar to portray social workers and physicians as being more utilitarian and nurses more egalitarian in rationing decisions. Implications for practice in a managed care environment are prcsented. [Article copies available for a fee frat11 The Haworth Docwner~t Delivery Setvice: 1-800-342-9678. E-mail addre~s:[email protected],rl Larry W. Foster is Associate Professor, Department of Social Work, Cleveland State University, Euclid Avenue at East 24th Street, Cleveland, OH 441 15. Linda J. McLellan is an Oncology Social Worker, Department of Social Work, The Cleveland Clinic Foundation, Cleveland, OH. Addrcss correspondence to Larry W. Foster, Department of Social Work, Cleveland State University, Euclid Avenue at East 24th Street, Cleveland, OH 441 15. This research was supported by the Dcpartmcnts of Social Work, Cleveland State University and The Cleveland Clinic Foundation. Q

Social Work in Health Care, Vol. 25(4) 1997 1997 by The Haworth Press, Inc. All rights reservcd.

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SOCIAL WORK IN HEALTH CARE

The allocation of health care resources continues to be hotly debated in light of trends in managed care. At issue is the rationing of services to control costs (McKinney, 1995), especially when this means "the denial of services demonstrated to be beneficial" (Boyle & Callahan, 1993, p. S6). How health care resources are allocated is a vital topic for social work, a profession historically committed to social justice issues. Dealing with ethical issues in rationing has been found to be the number one training need among hospital social workers nationwide (Foster, Sharp, Scesny, McLellan, & Cotman, 1993). Similarly, members of the American Nurses Association (1994) have ranked rationing as the most pressing ethical issue and, in recent years, increasing attention has been given to physician involvement in resource allocation and the ethical dilemmas they face in making such decisions (Leatt, Sharkee, Zager, & M e s h , 1991). Combined with reports of dissatisfaction with the term "rationing" (Blank, 1992; Churchill, 1988; Delamothe, 1992; Jonsen, 1992; Kilner, 1995), these findings give reason to suspect that rationing may run counter to the basic moral tenets of the health professions. Empirical research that examines the attitudes of clinical health professionals toward rationing of health care resources is needed. Inasmuch as rationing is interdisciplinary, and values (Mizrahi & Abramson, 1985; Roberts, 1989), ethical codes (McDonald, 1984; Sabin, 1994) and issues (Gramelspacher, Howell, & Young, 1986; Prescott & Bowen, 1985) are defined differently, relevant are areas of agreement and disagreement between the clinical health professionals who are faced with the impact of rationing decisions on themselves as individuals and as a team; understanding similarities and differences in attitudes toward rationing between professional subgroups may be important in promoting collaboration and moral discourse between them and in improving patient care (Fagin, 1992; Pike, 1991). There is a call in the literature for the moral basis of rationing to be publicly discussed in order that a consensus be reached about what is fair and just (Blank, 1992; Calman, 1994; Fleck, 1994a; Wikler, 1992; Zoloth-Dorfman & Rubin, 1995). This article is an attempt to contribute to such discussions by presenting findings from original research that assesses and compares professional acceptance of some considered moral judgments in the rationing of health care

L a n y W Fosler and Linda J. McLellan

I5

resources. It begins with an overview of the practice of rationing, its moral basis, and the relevance of professional affiliation to rationing issues.

LITERATURE

The Practice of Rationing Rationing in health care has been defmed as the setting of limits (Wikler, 1992) or the allocation of scarce resources (Mariner, 1995). Health care in the United States is routinely rationed. Lacking a national health insurance plan, much of the rationing is de facto (Kissick, 1992), ad hoc (Blank, 1992), and hidden-or not openly labeled as rationing and discussed as such (Fleck, 1994b). The primary way we ration health care services is by price and ability to pay (Churchill, 1988; Mariner, 1995). In addition, all clinical health professionals ration resources daily by how they choose to allocate their time, clinical skills, and access to programs and services (Calman, 1994). As conceptualized by Jecker and Pearlman (1992), rationing decisions may be either patient- or resourcecentered; in the former, decisions are based on individual characteristics (e.g., age, need, merit, quality of life or chances of survival), whereas in the latter decisions are based on ". . . features of health services themselves" (e.g., access to publicly funded high technology medicine and non-basic health programs) (p. 80). Dissatisfaction with rationing has been attributed to the fear of rationing. According to Jonsen (1992), "If there is fear of rationing, it is the fear of loss" (p. 7). Dissatisfaction has also been related to the ambiguous nature of the word rationing. As expressed by Kilner (1995), its ". . . association with a short-term policy for handling a temporary crisis, such as shortage of goods in wartime, makes it a misleading word to designate society's long-term task of health care provision" (p. 1067). Kilner recommends using the term allocation, as in micro- and macroallocation of health care resources. Whereas rationing raises fears of loss and potential tradeoffs between equity and efficiency, "resource allocation is often described as the balance of equity and efficiency" (Heginbotham, 1992, p. 497); this requires decisions about costworthiness and ultimately about priori-

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SOCIAL WORK IN HEALTH C A R E

ties of health care services (Boyle & Callahan, 1993; Sabin, 1994), as in the state of Oregon (Dougherty, 1991). Of all the rationing debates, none has become more controversial in recent years than patient-centered rationing based on age. For example, Callahan (1992) argues for reducing disparity and achieving equity in the allocation of health resources between children and the elderly through intergenerational transfers. In the book, Setting Limits: Medical Goals in an Aging Society, Callahan (1987) proposes that after a person lives out a normal life-span, medical care should be limited to relieving suffering and not oriented to resisting death. This, according to Hunt (1993), would ". . . undermine the autonomy of elderly patients and invoke the slippery slope toward involuntary forms of euthanasia" @. 19). Similarly, as noted by Jecker and Schneiderman (1992), labeling care as htile-or "pointless, useless, or hopeless," can serve as "convenient subterhge" for rationing decisions (p. 195). Intensifying the rationing debate is the shift from patient- to resource-centered rationing, particularly when the latter limits access to high technology medicine and non-basic health services by contractual arrangements that offer financial incentives to providers for containing costs (Kwon, 1996; Rodwin, 1995). Pressure to contain costs threatens to limit patient advocacy (Perloff, 1996), autonomy (Chervenak & McCullough, 1995), and confidentiality (Davidson & Davidson, 1996), and puts clinicians in what Brody (1991) calls a position of dual loyalty. Loyalty to the patient calls for the clinician to provide the best care possible, whereas loyalty to society as a whole calls for the clinician to contain costs.

Moral Basis of Ratiolrirrg According to Calman's (1994) discussion of justice and rationing, double agency-or loyalty to both clients and society-represents conflict between the ethical principles of autonomy and utility, or the rights of the individual versus the common good. Is health care a right or a privilege? Should rationing decisions be based on patient- or resource-centered criteria? What is a just allocation of health care resources? Lauve and McCullough (1994) describe our health care systems as ". . . a blend of concepts of distributive justice," i.e., utilitarian or "to each according to need," egalitarian

Larry 19: Foster and Linda J. McLellart

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or "to each equally," and libertarian or "to each according to merit" (pp. 4-5). Coombs (1990) sees the rationing debate as revolving around the competing ethics of egalitarianism and utilitarianism; whereas the former attempts to solve allocation issues by providing access to health care resources to everyone on the same basis, the latter holds a just allocation is providing the greatest good to the greatest number. Commenting further on utilitarianism, Coombs notes that "In its modern form it relies heavily on costhenefit analysis of proposed actions . . ." (p. 437). Is rationing based on the age, utility of outcomes, or chances of survival morally defensible? Or, should access to health benefits, goods, and services be provided to everyone on the same basis, as in egalitarianism? To what extent should one's social worthiness and/or ability to pay, as in libertarianism, serve to make rationing more or less acceptable to the clinical health professions? Such questions represent ethical "cut-points" in the rationing debate, forming the basis of some considered moral judgments in rationing health care. Professional Affiliation and Rationing Conflicting moral positions in rationing decisions may be seen as representing different worldviews which ". . . are not only composed of our knowledge and concepts but also of our attitudes, values, and opinions" (Sue, 1991, p. 300). For example, nursing is characterized primarily by" health maintenance, preventive, and caring functions . . . ," whereas medicine is characterized primarily by ". . . curative, diagnostic, and prescriptive functions . . ." (Fagin, 1992, p. 302). The ethic of medicine includes an emphasis on cure/ healing of diseasetpathology. The ethic of care as described in social work, ". . . is essentially contextual and involves an emphasis on the importance of relationship and responsiveness to others" (Imre, 1989, p. 22). Both ethics focus on the individual patient and require the clinician to act in ways considered for the benefit of the patient. Thus, one might expect physicians and nurses to give primacy to the individual, perceive health care as a right, and embrace a patient-centered ethic in rationing decisions. Unlike codes of ethics in medicine (Sabin, 1994) and nursing (Mohr, 1995), social work's code of ethics encompasses both the ethic of care and of justice and addresses responsibility to both individual and society;

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the revised code (1996) strengthens commitment to client advocacy, diversity, cultural competence, and sociopolitical action in the broader society. This underscores the importance of relations and membership (Constable, 1989) and of balancing self-determination and the common good (Wesley, 1996). As expressed by Siporin (1989), social work seeks ". . . to help people maintain, restore, and enhance their social functioning and competencies as members of their communities" (p. 43). Thus, social workers may be more likely than physicians and nurses to perceive health care as both a right and privilege and embrace both patient-centered and communitarian ethics in rationing decisions. Inasmuch as the care perspective emphasizes the importance of relationship with and responsiveness to others, and nurses spend relatively more time at the bedside than do other clinicians, nurses may be more likely than physicians and social workers to subscribe to an egalitarian world view in rationing decisions. Given medicine's focus on the individual patient and emphasis on diagnosis and cure of pathology, physicians may be more likely than nurses and social workers to subscribe to a utilitarian worldview that relies on a case-by-case costhenefit analysis of clinical actions and outcomes in rationing decisions. Given the social work ethic is a combination of the care and justice perspectives, representing ". . . a vision of how people can act rightly in relation to each other and live together for their common good" (Siporin, 1989, pp. 42-43), social workers may be more likely than physicians and nurses to subscribe to a utilitarian world view in rationing decisions that relies on promoting the common good. Notwithstanding differing worldviews, perhaps due to different socialization processes (Mizrahi & Abramson, 1985), changes in the philosophy and structure of health care delivery are causing professional identities, roles, and relationships to be in flux. These changes are creating uncertainty and the need for collaboration (Netting & Williams, 1996), collective moral decision-making (Abramson, 1984), or a blending of moral perspectives (Pike, 1991). As Pike asserts, "collaborative practice can transform the meaning of conflicting moral positions" (p. 358). Thus, in support of the call for a public discussion of the moral basis of rationing, the authors' research was guided by the following questions:

L a n y K Foster and Linda J. McLella~r

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1. Given some considered moral judgments in the rationing of health care resources, which are the least and which are most acceptable to social workers, physicians, and nurses? 2. Is there a significant difference between social workers, physicians, and nurses regarding the acceptability of some considered moral judgments in the rationing of health care resources? 3 . To what extent do selected background characteristics of social workers, physicians, and nurses account for significant differences between them regarding the acceptability of some considered moral judgments in the rationing of health care resources?

METHODOLOGY Suniple: Setting for this exploratory-descriptive study was a large urban teaching hospital. After receiving approval for the study in the Summer of 1995, self-administered survey questionnaires containing six background items and eighteen study items were distributed to social workers (11 = 45), medicaVsurgica1 registered nurses (n = 300), and resident physicians (n = 221); the response rate for social workers was 69 percent (n = 3 I), compared to 23 percent each for nurses (11 = 69) and physicians (11 = 5 1). Dafu Collection: Study participants were asked to indicate on a Likert-type scale (ranging from 1 = strongly disagree to 4 = strongly agree) the strength of their convictions for each of the eighteen study items-or statements of considered moral judgments in the rationing of health care resources (Table 1). These items were adapted to the present research from Leonard Fleck's (1991) work o n justice and rationing and are representative of "ethical cutpoints" in the rationing debate. Items soliciting background information included participant age, gender, years of practice, professional category (social work, physician, and nurse), advance directive (i.e., living will and/or durable power of attorney for health care), and whether they believe health care to be a right, a privilege, both a right and privilege, or neither. Age and years of practice experience were included as variables in the study because methods of moral reasoning have been found to differ between

TABLE 1. Rationing Health Care Resources: Some Considered Moral Judgments S1.

No one has an unlimited right to health care

52. No one has a moral claim to futile or virtually futile health care resources S3. The sociaVeconomic worth of individuals is not a morally relevant consideration in determining fair access to health care resources 54. Those who have lived out a natural life span have less of a claim to expensive life-prolonging medical resources than those who hope to

achieve such a life span

S5. Any rationingproposaVprinciplethattargetstheelderly must becoupled withequally effective proposals/principlesthatreducethewasteful use of health resources by the non-elderly

S6. No one has a moral claim to merely marginal health benefits especially when there are more urgent unmet health needs in society S7. The magnitude of a likely benefit from a specific health intervention relative to cost is a morally legitimate consideration in establishing limits and rationing processes

S8. All rationing policy decisions ought to be a product of public, visible decision-makingprocesses S9. Those who have lost the capacity to have a self, that is, the capacity to have meaningful relations with others, the capacity to connect their past with projects for the future and the capacity to be a center of experience, no longer have just claims to expensive life-prolonging medical resources S10. No new technologies should be developed or applied to the old that are likely to produce only chronic illness and a short life, to increase the present burden of chronic illness, or to extend the lives of the elderly but offer no significant improvement in their quality of life

Sll. A reasonable moral criterion for assessing the relative priority of competing health needs would be the degree to which a specific health intervention protects or restores effective equality of opportunity

512. It is morally legitimate to givegreater priority to funding those health interventionsthat are likely to forestalldeath or restore healthlfunction for the relatively younger members of society S13. Rationing decisions are more likely to be just if they are decisions that are self-imposed rather than being imposed by some (healthy individuals) on others (sick and vulnerable individuals) 514. No one has a moral claim to non-costworthy health careor the sort of care that would not be purchased by a reasonable prudent purchaser with a limited budget 515. Physicians are not morally obligated to do evelything medically possible on behalf of their patients because it will often be the case that patients will have no just claim to those resources; or else, they may have a claim, but there may be other patients who have a stronger claim to that same resource 516. Physicians have no moral right to make unlimiteddemands upon public resources, or hospital resources, or insurance resources on behalf of their patients, especially when the making of those demands result in making those who are already least well off so far as health is concerned even worse ofl 517. Individual patients do have a strong moral right to use their purely private resources in terminal circumstances to purchase what most

people would judge to be non-costworthy health care. But they may not use these resources to purchase health goods that are scarce in an absolute sense 518. Physicians cannot be absolutely unwmpromised advocates of a present patient's interests because every physician has other patients (as do health professionals) who make just claims of their time and skills Source.Adapted with permission from Fleck, L. (1991). Just Caring: Justice,ResourceAllocation, and the Terminally Ill, Eth~cs-in-Formation,3 ( 4 8 5),pp. 6-7

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younger and older clinicians (Silver & Weiss, 1992). Gender was included because previous work (Gilligan, 1982) has characterized males and females as having different moral perspectives. The variable health care as a right and/or privilege was included because it is a core construct in rationing debates. A question about personal advanced directives was included because having one presumes serious consideration of limit-setting, if not rationing, in end-of-life decisions. Finally, respondent comments were solicited on the back of the questionnaire to add insight to the quantitative findings. Data Analysis: Data were grouped by profession into social work, physician, and nurse subgroups. Descriptive statisticson background items and on each of the 18 study items-or statements of considered moral judgment-were generated for the overall sample and for each professional group. Mean responses for each study item by professional group were rank-ordered; by observing items with the highest and lowest means we were able to obtain a heuristic assessment of statements of considered moral judgment each professional group felt strongest and weakest toward. Statistically significant differences among the three professional groups were assessed using Kruskal-Wallis tests; these are nonparametric equivalent of analyses of variance and were used because the data did not meet the distributional requirements necessary for the classical one-way AWOVA (Gibbons, 1993). Because there were 18 comparisons and the statements were highly intercorrelated, the chance of falsely concluding that there is a significant difference (Type I error) is increased. To account for that we adjusted our significance level to consider only p-values of .O1 or lower as statistically significant. TO determine which among the three professional groups accounted for the significant differences, nonparametric Mann-Whitney-Wilcoxon rank sum tests (Gibbons, 1993) were performed for painvise comparisons on those statements having a significant difference between groups; a level of .02 was used to determine statistical significance instead of .05 because of the number of comparisons made. TOdetermine the direction of significant differences in the painvise comparisons, we used group means; the group with the highest mean felt the strongest agreement with the item. Analysis of covariance was utilized to assess the extent to which age and years of practice experience accounted for significant differences between

Lany W Foster arid Linda J. McLellarl

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the three professional groups on the acceptability of moral judgments in rationing; variables of gender, advance directive status, and health care as a right and/or privilege were not robust enough to include in this assessment. Qualitative data were content analyzed and grouped into categories of patient- and resource-centered rationing.

FINDINGS Sainple Cliaracteristics The mean age for social workers was 42 (range: 30 to 56 years), compared to 30 (range: 25 to 38) for physicians and 34 (range: 22 to 57) for nurses. Average years of experience for social work was 14 (range: 3 to 32), compared to 4 (range: 1 to 12) for physicians and 10 (range: 1 to 29) for nurses. A large majority of social workers (96%) and nurses (90%) were women, compared to only 24 percent for the physician group. Based on data from the study hospital's personnel ofice, these percentage breakdowns are similar to the population of social workers, physicians, and nurses from which the study sample was drawn. Also typical, a large majority (86%) overall did not have an advance directive, although social workers were somewhat more likely (29%) than physicians (8%) and nurses (12%). Overall, a large majority (62%) believed health care to be both a right and a privilege, followed by either a right (28%) or privilege (4%); nurses were slightly more likely (31%) than social workers (26%) and physicians (26%) to believe health care to be a right only.

Acceptability of Coilsidered Moral Judgineiits in Ratio~ing Table 2 compares social work, physician, and nurse sub-groups on the acceptability of statements of moral judgment in rationing of health care; based on mean responses, statements are given a rankorder by professional group, ranging from 1 (most) to 18 (least) acceptable. Most acceptable to social workers, physicians, and nurses is the statement that one's social/economic worth is not a morally relevant

TABLE 2. Acceptability of Some Considered Moral Judgments in Rationing Health Care Resources: A Rank-Order Comparison of Clinical Health Professionals Statements of Moral Judgment

Rank Orderinga by: Social Worker Physician Nurse (n = 31) (n = 51) (n = 69)

No one has an unlimited right to health care resources No one has a moral claim to futile or virtually futile health care resources The sociaVeconomic worth of individuals is not a morally relevant consideration in determining fair access to health care resources Those who have lived out a natural life span have less of a claim to expensive life prolongingmedical resources than those who hope to achieve such a life span Any rationing proposaVprinciplethat targets the elderly must be coupled with eauallv effective ~rooosals/~rinci~les that reduce the wasteful use of health care resources bythe non-elderly No one has a moral claim to merely marginal health benefits especially when there are more urgent unmet health needs in society The magnitude of a likely benefit from a specific health intervention relative to w s t is a morally legitimate consideration in establishing limits and rationing priorities All rationing policy decisions ought to be a product of public, visible decision. making processes

Significance of Differences P-Values

S9. Those who have lost the capacity to have a self, that is, the capacity to have

12

11

11

9

8

10

18

13

9

5

14

15

15

18

meaningful relations with others, the capacity to connect their past with projects for the future and the capacity to be a center of experience, no longer have just claim to expensive life-prolonging medical resources S10. No new technologies should be developed or applied to the old that are likely

to produce only chronic illness and a shon life, to increasethe present burden of chronic illness, or to extend the lives of the elderly but offer no significant improvement in their quality of life S11. A reasonable moral criterion for assessing the relative priority of competing

health needs would be the degree to which a specific health intervention protects or restores effective equality of opportunity S12. It is morally legitimateto give greater priority to funding those health

interventions that are likely to forestall death or restore healthffunction for the relatively younger members of society S13. Rationing decisions are more likely to be just if they are decisions that are

self-imposed rather than being imposed by some (healthy individuals)on others (sick and vulnerable individuals) S14. No one has a moral claim to non-costworthyhealth care-or the sort of care

that would not be purchased by a reasonable p ~ d e npurchaser t with a limited budget S15. Physicians are not morally obligated to do everything medically possibleon

behalf of their patients because it will often be the case that patients will have no just claim to those resources;or else, they may have a claim, but there may be other patients who have a stronger moral claim to that same resource

k

TABLE 2 (continued) Rank Orderinga by: Social Worker Physician Nurse (n = 51) (n = 69) (n = 31)

Statements of Moral Judgment S16. Physicians have no moral right to make unlimited demands upon public resources, or hospital resources or insurance resources on behalf of their patients, especially when the making of those demands results in those who are already least well off so far as health is concerned even worse off

13

16

S17. Individual patients do have a strong moral right to use their purely private resources in terminal circumstances to purchase what most people would judge to be non-costworthy health care. But they may not use these resources to purchase health goods that are scarce in an absolute sense

6

7

S18. Physicians cannot be absolutely uncompromised advocates of a present patient's interests because eve& physician has other patients (as do other health professionals) who make just claims of their time and skills

10

13

--

-

-

Significance of Differences P-Values

10

.40

9

0.33

-

al = most acceptable to 18 = least acceptable, based on mean responses (1 = strongly dlsagree to 4 = strongly agree) for each statement by profess~onal group *Stat~st~cally slgnlf~cantat the 0 01 level, uslng the Kruskal Wallis Test

Larry M Foster atid Linda J. McLellari

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consideration. That no one has a moral claim to futile health care resources and that there should be equity between the elderly and non-elderly in rationing are other statements about which there was consensus. Social workers agreed least with statements giving priority to younger members of society in the allocation of resources, even in rehabilitative and in end-of-life situations. Surprisingly, also least acceptable to social workers were moral judgments appearing to give greater consideration to societal than to individual needs, even when care is non-costworthy or marginally beneficial in the context of more urgent unmet needs. These findings were generally consistent with physician and nurse responses.

Sigrtrjicarlt Differerrces Of the 18 statements of moral judgment, the three groups differed significantly on seven. As illustrated in Table 3, significant differences were found between nurses and social workers on four statements and between nurses and physicians on six statements. Three statements (S4, S9, S 12) appear to be about patient-centered rationing and four (Sl, 57, S15, S17) about resource-centered rationing; it is noteworthy that both were less acceptable to nurses than to social workers and physicians. That no significant differences were found between social workers and physicians is also noteworthy. A majority of significant differences were found in the top (most acceptable) and bottom third (least acceptable), which is not surprising because this is where respondents would have the strongest convictions. Although all professional groups tended to agree that no one has an unlimited right to health care and that a cost-benefit ratio is a morally legitimate consideration in rationing, social workers were more likely and physicians significantly more likely than nurses to agree with these statements. Both social workers and physicians were significantly more likely than nurses to agree that terminally ill patients have a right to use private resources to purchase non-costworthy health care so long as these are not scarce in an absolute sense. On the other hand, although all groups least agreed with limiting life-prolonging resources to persons who have lived out their natural life-span and to persons who have lost the "capacity to have a self," nurses were significantly more likely than social workers and

TABLE 3. Acceptability of Some Considered Moral Judgments in Rationing Health Care Resources: Mean and Pairwise Comparisons of Clinical Health Professionals on Items of Significant Difference Pailwise Comparisons:

Statements of Moral Judgment

Profession

S1. No one has an unlimited right to health care

Nurse Physician Social Worker

S4. Those who have lived out a natural life span have less of a

Nurse claim to achieve expensive life-prolonging medical resources Physician than those who hope to achieve such a life-span Social Worker

S7. The maunitude of a lhkely benefit from a s~ecifichealth inteweniion relative to cost is a morally legitimate consideration in establishing limits and rationing priorities


S9. Those who have lost the capacity to have a self, that is, the capacity to have meaningful relations with others, the capacity to connect their past with projects for the future and the capacity to be a center of experience, no longer have just claims to expensive life-prolonging medical resources


Nurse vs. Physician (n = 69) (n = 51) Meana P-Value

Nurse vs. Social Worker (n = 69) (n = 31) P-Value

512. It is morally legitimate to give greater priority to funding those Nurse health interventions that are likely to forestall death or restore Physician healthlfunction for the relatively younger members of society Social Worker

2.34 2.84 2.55

0.0003'

S15. Physicians are not morally obligated to do everything medically possible on behalf of their patients because it will often be the case that patients will have no just claim to those resources; or else, they may have a claim, but there may be other patients who have a stronger moral claim to that same resource


2.15 2.43 2.63

0.04

517. Individual patients do have a strong moral right to use their Nurse purely private resources in terminal circumstances to Physician purchase what most people would judge to be non-costworthy Social Worker health care. But they may not use these resources to purchase health goods that are scarce in an absolute sense

2.50 3.02 3.07

0.0002'

aMean responses based on 1 = strongly disagree to 4 =strongly agree for each statement 'Statistically signlficanlat the 0.02level, uslng the Wilcoxin rank sums test

0.0004'

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physicians to disagree with these statements. Nurses were also significantly more likely than physicians and more likely than social workers to disagree with giving priority to funding health interventions likely to forestall death or to restore health for younger members of society. Furthermore, nurses were significantly more likely than social workers and more likely than physicians to disagree with the statement that a physician's moral obligation to do everything possible for patients is not absolute, but relative to the moral strength of other patients' claims. After adjusting for age and years of experience, significant differences remained significant in all cases.

DISCUSSION Statements of moral judgment least and most acceptable to all professional groups appear to underscore the conflict in our rationing debates between belief in primacy of self and identification with the larger community. On the one hand, social worker, physician, and nurse support for an individual's moral claim to non-costworthy care and to merely marginal health benefits appears to underscore belief in primacy of self and health care as a right, as does their rejection of patient-centered rationing based on socioeconomic worth and age, even in rehabilitative and end-of-life situations; otherwise, as one nurse comments, "criteria of how old, how sick, and how poor would have to be developed." Such findings may mirror an unreadiness in society to place needs of the larger whole before the needs and desires of each individual. Yet, on the other hand, that all professional groups agreed no one has a claim to futile care is consistent with their reported belief that an individual's right to health care should not be an unlimited right, but rather both a right and a privilege and, thus, considerate of the common good. Illustrative is one social worker's comment: "I know that 80+ year olds die million dollar deaths, but there are also many highly compromised infants and children who live million dollar years. I question the value on either end." Similarly, a physician respondent stated: "Young or old, if patientslfamilies wish to pursue futile options, they should be counseled against it; if they still wish to pursue these options, payment should be their responsibility."

Larry IK Foster and Linda J. McLella~~

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However, one nurse stated: "I feel patients should make their own choices about care," a statement which is consistent with the finding that nurses were more likely than physicians and social workers to perceive health care as a right only. That social workers and physicians were more likely than nurses to consider such patient factors as age and quality of life, as well as availability of resources and cost-benefit ratios may, as expected, portray them as being more utilitarian and nurses more egalitarian in rationing decisions. Perhaps physicians by the reality of capitated fees and prospective payment and social workers by training are more focused than are nurses on the macro as well as the micro-level issues in the allocation of health care resources. How the egalitarian appearing stance among nurses may impact interdisciplinary collaboration is unclear, but it seems to the authors that in practice it may be contributory to social workers and physicians reacting defensively to taking on a gatekeeping role in rationing. Surprising was the finding of no significant differences between social workers and physicians on the study items. This seems to contrast with the professional literature that underscores value differences between the two disciplines in approach to delivery of care (Mizrahi & Abramson, 1985; Roberts, 1989). In the case of health care rationing, social workers and physicians may be finding common ground as they negotiate conflict in their roles as doubleagents, serving both individual and society by providing the best care possible and simultaneously containing costs. Common ground may also be emerging as social workers and physicians struggle with threats to professional autonomy in rationing decisions and coalign for support. Such mutuality is consistent with a more interdependent model of collaboration that may be emerging in response to increased pressure for accountability and dissatisfaction with practice circumstances (Abramson & Miuahi, 1996). This emerging need for collaboration may increasingly override differences between the clinical health professions on ethical cutpoints in the rationing debate, which may also explain why age and years of professional experience did not account for the significant differences between the three professional groups as expected. Finally, although considering cost-benefit ratios in rationing decisions was found to be more acceptable to social workers and physicians than

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to nurses in the quantitative data, concerns were expressed by all three professional groups in the qualitative data. In the words of one physician, "The right to decide what is morally and medically necessary is being taken out of the hands of those best educated to make those decisions (health care providers) and is placed in the hands of those not as well qualified (insurance companies)." This concern is reflected in another comment by a nurse who stated: "I feel decisions are being made about rationing health care for people and I don't feel a part of it." A social worker concluded, "Right now I think that private or commercial insurance companies are rationing health care." Thus, it is not surprising that responding social workers, physicians, and nurses strongly agreed that rationing decisions ought to be a product of public, visible decision-making processes.

CONCLUSIONS AND IMPLICATIONS The reader is cautioned that respondent attitudes toward rationing may not be representative due to a self-selection process; study respondents may have been more sensitive to ethical issues/cutpoints raised in the study than the larger professional groups from which they were drawn. Also, respondents were drawn from one urban tertiary care center. Thus, the addition of study cites and a higher response rate would have enhanced validity of any generalizations. The authors acknowledge a modest data set and analysis and the need for much more empirical data on the acceptability of rationing decisions among the clinical health professions. We hope that others will add to our beginning effort. Labeling considered moral judgments as patient- or resource-centered rationing based on empirical induction using factor analysis is recommended in hture research to more validly specify the nature of rationing. Notwithstanding, study findings serve as a reminder that values and economics are indivisible in rationing decisions; such decisions should be perceived as both ethical and economic. We are also reminded that professional roles and moral obligations in rationing are separate but related problems, requiring both a social role and ethical analysis. As found in the study, the rejection of patient-centered rationing based on age and socioeconomic worth means neither the rejection of primacy of self nor the embracement of re-

Larry

W

Foster and Litrdu J. McLellut~

33

source-centered rationing and the common good. Pivotal to the acceptability of either patient- or resource-centered rationing may be the amount of decision-making discretion the clinician has. The opportunity of clinicians to exercise their moral judgment, based on their perceptions of quality-of-life, medical necessity, and futility, may become increasingly limited by organizational and third-party payer mandates to contain costs. Dissatisfaction with rationing is likely to increase as trends in managed care shift the locus of decision-making from patients and clinicians to care managers. As social workers, we are often placed in the position of having to "explain" the limitations set forth by the third-party payers and of helping the patientlfamily deal with the socioemotional impact of limits to care. To survive in a managed-care environment characterized by resource-centered rationing, we will need to be proactive, empowering ourselves, our colleagues, and our clients to organize at the community level, and to educate consumers of health care about choices and limits in care. We will need to further refine our assessments for high-risk factors in patient care, track patients for continuity of care, and tie the evaluation of our success to medical outcomes as well as to cost savings. At the same time, we will need to challenge clinical actions and outcomes that are non-therapeutic and non-moral-or when resource centered rationing limits patient access to needed care and favors efficient over quality care. Social workers along with other clinical health professionals will need to continually address how to optimize care within fiscal and political constraints. Based on its historic stance of evaluating institutions as well as individuals, social work can take leadership in the call for a new ethics-or the development of ethical standards for health care organizations, shifting the focus from clinical eth'ics to organizational (Wolf, 1994) and social (Veatch, 1991) ethics. New opportunities for interdisciplinary collaboration may be occurring. Inasmuch as trends in managed care include physicians and social workers as gatekeepers, this may further distance them from bedside nurses, particularly in cases where patient advocacy conflicts with a just allocation of resources. Uneasy compromises will stretch our values. A public forum is needed to discuss, if not negotiate, the tensions that will surely emerge. Accepted for Publication: 02/24/97

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