Medical Ethics and Decision Making Do Doctors Need More Guidelines?

New Revolution in Ethics

In 1988, what many called the 'third revolution' in medical care came about (Dunevitz, 1999). The first revolution was after the Second World War, and this caused an explosion in the number of hospitals and doctors, as well as the research that went into the field (Dunevitz, 1999). Medicare and Medicaid were created and the field of medicine was growing so rapidly that it was hard to follow it and understand everything that was happening to it (Dunevitz, 1999). In the 1970's, cost and how to contain it became more of an issue than the growth of medicine and not only employers but the government began to work against the costs that were getting out of control (Dunevitz, 1999).

This caused the creation of managed care, among other measures (Dunevitz, 1999). Even though the control of these costs was very important, there came a time where it became difficult to judge the quality of care that many patients were receiving and this led to the third revolution - accountability and assessment (Dunevitz, 1999). The purpose of this literature review is to discuss the revolution of accountability and assessment, and what it means for doctors in the UK and in America. While the UK should be the main focus, America has many problems with the same issue and much of the information to be found on the subject deals with America. Other information is largely universal, as doctors everywhere must deal with ethics, guidelines, and responsibility to their patients (Dunevitz, 1999).

The significance of this is very great and should not go unnoticed (National, 1980). Looking at the chronology that was just mentioned above helps to create an understanding of how accountability became so important in the medical profession and why it still remains one of the most important issues that all doctors, hospitals, and insurance companies must consider (National, 1996). In the new era of health care, the assessment of quality occupies an important area, especially when it comes to delicate and often controversial topics such as abortion, plastic surgery, difficult diagnoses, and assisted suicide (Witkin, 2000).

While some of these topics are more controversial than others, all of them are within the realm of concern for doctors and hospitals, and whether more guidelines for these issues are needed is a focus of concern for almost all countries of the world (Denhardt, 1991). This is especially true in the more developed countries where there are more options and freedoms when it comes to medical care that is sometimes not necessary but is chosen by the patient for various reasons (such as in most abortions or plastic surgery cases) (Kutchins, 1991).

The Importance of Quality

In addition to this quality assessment, quality improvement has become increasing important (Kleinman, 2001). It is now not enough to look at something and determine whether quality is present (Kleinman, 2001). Now, if the quality is not present that must be corrected, so that quality can be created where there previously was none, and so that quality can be improved where it previously was low (Kleinman, 2001). This idea of quality has become fundamental to health care and is not something that is going to be diminishing as time goes on (Kleinman, 2001). The rising costs of health care, both in the UK and abroad, are causing many to reconsider some of their health care options and are forcing many to go without insurance (Kleinman, 2001).

Many countries have government plans that can help those that are most in need, and some also have insurance plans that cover everyone, regardless of their income, class, or status, but even these programs have their flaws (Kleinman, 2001). Some individuals may not see this issue as having ties to quality, but it does (Kleinman, 2001). For example, there are concerns in many countries that those who receive government assistance for health care do not get the same

The same concern is expressed for those that have HMOs, PPOs, and other health care plans that are not the same as private insurance (Kleinman, 2001).
Unfortunately, private insurance and the high quality of care that originally came with it is dwindling and many people cannot afford to have it (Daley, 1999). Most of those that have it are those that are retired and were fortunate enough to have good jobs through strong companies that continue to pay their insurance premiums (Cohen, 2001). There are fewer and fewer of these people every day as the populations ages and more companies stop offering these kinds of benefits to their workers and retirees (Mattison, Jayaratne, & Croxton, 2002).

One of the reasons that doctors and hospitals are struggling with the quality area of the health care issue is that there are many other issues that they must deal with, and they face increasing pressure to raise their rates and treat patients only for what they absolutely need because their health care plans will not pay for anything that might cost extra (Mattison, Jayaratne, & Croxton, 2002).

Even if extra tests or medications are important, many doctors cannot even tell their patients about them if they know that the patient's health care plan will not cover the cost (Mattison, Jayaratne, & Croxton, 2002). This is not quality, but it is what is happening to much of the world (Mattison, Jayaratne, & Croxton, 2002). There is a huge battle going on at present between cost and quality, and it seems that cost is winning (Mattison, Jayaratne, & Croxton, 2002). However, quality has begun to fight back and there is hope yet that health care can be adjusted so that doctors and hospitals will once again be able to provide the high quality of care that they gave in the past, without fear of reprimand or low payment (Mattison, Jayaratne, & Croxton, 2002). Another concern with the health care problem is that it is arguable as to what makes something 'good quality' (Mattison, Jayaratne, & Croxton, 2002).

It can be a good value for the money, lead to increased longevity, lead to a better quality of life, and many other things (Langs, 1976). Agreeing on a concise and concrete definition of quality healthcare is a sticking point for many, and until a way of determining the quality of health care can be created it is difficult to compare it to the current quality of health care in order to see if the two match up or where improvements need to be made (Bok, 1980). By creating an assessment that will allow this comparison to be made, the next step will be taken toward making sure that good quality health care is something that is available to all and that standards of care are kept high for all who need medical assistance (Campen, & DiLoreto, 2000).

Guidelines, Accountability, and Rapid Expansion

It will also help to show the guidelines that may be needed where delicate and controversial topics are dealt with because many doctors are better than others at concepts such as 'bedside manner' (Davies, 1999). While there are some that feel this is not as important as the treatment or medication that is received, it is part of the notion of quality and therefore it becomes important to the patient (Victor & Cullen, 1997). What is important to the patient should therefore be seen as something that is important to the doctor and the hospital, but this is too often not the case with many medical professionals (Taylor, 1999).

To some degree, this is not their fault. When health care was expanding so rapidly many medical professionals put their time into research that would benefit future patients, and this was undoubtedly important (Kanuha, 2000). When cost containment begin to be seen as problematic, many medical professionals devoted much of their time to concerns about how they could lower the costs, both for themselves and their patients (Goold, 2001). Unfortunately, there was no time taken when all of this was going on for doctors and hospitals to focus on the quality of care that their patients felt they were getting (Goold, 2001). Now, quality has become a large issue and many medical professionals are unprepared because they were not trained for it (Goold, 2001).

They were trained to research and figure out how to help more people with new scientific advances, and when needs changed they were trained to deal with costs and financial information, but they were never trained to deal with the actual quality of care that they were providing to their patients (Goold, 2001). This does not mean that they did not concern themselves with whether their patients got better or not, but only that they did what they could for their patients based on the guidelines that were available through the patient's health plan and knew that they must leave it at that because they would not get paid for anything else (Goold, 2001). Doctors are often conflicted emotionally by…