Introduction As rising health care costs continue to pose problems for stakeholders in the health care industry, the question of just how to solve this dilemma remains an elusive one. The trouble is that it is not just a question of cost—but also a question of how to balance quality care with efficiency of care in an industry where for-profit facilities seem more and more to put profits before people, as opposed to putting people before profits (a concept that might naturally find expression in a profession so inherently oriented to helping those in need). While stakeholders understand that in order for professionals to provide quality care and for patients to receive it there must be some cost and some efficient system in place to expedite delivery, they must also realize that a balance of quality and cost-efficiency must be acquired in order for the industry to remain operable over the long run (Sikka, Morath & Leape, 2015). This paper will discuss the problem of the health care as an industry whose services have become almost too expensive to be obtained by the people who need them most.

Background of the Key Ethical Issue and Its Relevance

Provision 1 of the ANA Code of Ethics states that “the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.” As this is the first provision of the ANA Code of Ethics, it is worth focusing on, especially in the light of the problem identified in this paper. It must be noticed that the provision does not include a stipulation regarding cost of care—i.e., something like “so long as the patient can afford the expenses associated with the care received.” No, the nurse’s most prized and pronounced ethic within the Code is to demonstrate respect for every patient and to practice the art of nursing for every patient who comes for care. This ethical principle is critical to the nurse’s sense of mission, self and vision. Within it are the seeds of the Code’s second and third provisions—namely that “the nurse’s primary commitment is to the patient, whether an individual, family, group, or community” and that “the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient” (ANA, 2010).

The relevance of these three provisions within the ANA Code of Ethics to the issue of balancing quality care with efficiency of care is that each serves as a guide for how health care should be directed. Each puts the person at the center of the care giving process. Not one of them mentions the for-profit nature of the industry today—mainly because the profit side of the business is not the nurse’s concern. The concern of the nurse is to provide quality care for every patient. The nurse’s concern is to put people before profits. This must be kept in mind by all stakeholders, for if the nurse is unable to fulfill this ethical provision for whatever reason—whether it is because health care costs have skyrocketed to the point where patients do not feel comfortable seeking care or whether it is because health care facility administrators want care to be provided in a way that emphasizes maximizing profits instead of maximizing quality of care—the nurse and all other health care providers are very likely to experience a very low sense of job satisfaction, as Sikka et al. (2015) point out in their study on the experience of providing care. The ethical issue at play in the health care industry today is this all-important question of which should come first—the people or the profits? Understandably, the latter should flow from an appropriate level of attention given to the former—but in the highly corporatized business world of health care today, what gets deemed an “appropriate level of care” does not always correlate with the ethical provisions provided to nurses in the ANA Code of Ethics—primarily because effecting correlation might cut into profits. However, if there...

This is the essence of the ethical problem underlying the issue.
Scholarly Literature

Bodenheimer and Sinsky (2014) note that the Triple Aim of health care—“enhancing patient experience, improving population health, and reducing cost”—is a commonly accepted standard among health care practitioners, yet low patient satisfaction, poor health outcomes and increased costs all appear to be the product of the current health care system (p. 573). In other words, far from achieving the aims that health care providers have in mind, the industry is actually seeing the exact opposite of what it intends to achieve come to fruition. Sikka et al. (2015) provide a fourth aim: “improving the experience of providing care” (p. 608). This fourth aim is helpful in providing context for the troubling situation in which the health care industry finds itself today: the experience of providing care has fallen to a standard below where it should be. Access to care is minimal for a substantial population of patients; quality care is marred by nurse error, unaffordable care, high cost prescriptions, prescriptions that lead to addictions, and so on (Kolodny, Courtwright, Hwang et al., 2015). The experience of providing care is falling short of what stakeholders expect.

Sikka et al. (2015) show that experience is not just bad for patients—it is also bad for providers: “the evidence that the healthcare workforce finds joy and meaning in work is not encouraging. In a recent physician survey in the USA, 60% of respondents indicated they were considering leaving practice; 70% of surveyed physicians knew at least one colleague who left their practice due to poor morale” (p. 609). The issue of low morale among health care providers stems from poor experience of providing care; and that poor experience is related to the problem of balancing quality care with cost efficient delivery. In an industry that is increasingly focusing on profits and costs, the question of care and the importance of the patient-provider relationship is getting lost in the mix (Dowsett & Dowsett, 2015; Jennings, Clifford, Fox, O’Connell & Gardner, 2015; Baummer-Carr & Nicolau, 2017). In order to provide an ethical solution that can help to restore the balance between quality care and cost-efficiency so as to help the industry to obtain all of its objectives, the research shows that health care providers must be willing to put people before

Ethical Principles That Guide This Issue

The ethical principles that guide this issue are that health care providers and specifically nurses are bound to provide quality care for every patient who comes to them, without regard for socioeconomic status. Implicit in this principle, which is explicitly stated in the ANA Code of Ethics’ first three Provisions, is the notion that nurses must give quality care wherever it is needed; people are the first priority of the nurse. This principle is, in today’s health care industry, directly and inherently in conflict with the principle of business, which is to make money by minimizing costs. The problem and source of conflict is that in providing maximum quality care, the cost of this care cannot be quantified, at least not by the nurse who is truly dedicated to practicing the profession in accordance with the first three provisions of the ANA Code of Ethics. Unless the patient comes first in the practice of quality care, the nurse has no reason to be there.

Viewpoint of Stakeholders/Viewpoint of the ANA

Stakeholders in health care all have different viewpoints. Stakeholders in administrative positions come from the standpoint that health care services must be of a high quality but that they must also be cost-efficient in their delivery (cost-efficient for the provider that is). Administrators recognize that service must be high in order to be of use to patients but they also recognize that there is a business aspect to the service that is a top priority as well and that if the…