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Silva Capriano (ETHICS)

Silva Capriano (ETHICS)

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Published by: Nanda Masraini Daulay on Nov 07, 2012
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Silva, Mary Cipriano, PhD, RN, FAAN (June 10, 1998). FinancialCompensation and Ethical Issues in Health Care Online Journal of Issues inNursing Avai
Silva, Mary Cipriano, PhD, RN, FAAN (June 10, 1998). Financial Compensation and EthicalIssues in Health Care Online Journal of Issues in Nursing Availablehttp://www.nursingworld.org/ojin/tpc6/tpc6_4.htm© 1998 Online Journal of Issues in Nursing Article published June 10, 1998FINANCIAL COMPENSATION AND ETHICAL ISSUES IN HEALTH CAREMary Cipriano Silva, PhD, RN, FAAN AbstractAs health care workers enter the twenty-first century, they must understand the relationshipsamong market-driven forces, the health care workforce, and financial compensation. Thisunderstanding can be facilitated by a grasp of utilitarian ethical theory and by ethical tenets of  justice such as distributive justice, material principles of justice, and justice as fairness.Health care workers also need to understand how unfair financial compensation candemoralize them and compromise their values. However, professional associations and healthcare managers can take a proactive stance to ensure that organizations are ethical in theirapproach to financial compensation.FINANCIAL COMPENSATION AND ETHICAL ISSUES IN HEALTH CARE"Ethics asks us to resist close-heartedness, to keep the heart open." Weston(1997, p. 67)  As health care providers enter the twenty-first century, they are riding a tidal wave of changein health care. This tidal wave has a dual crest -- one related to market-driven forces and theother related to the health care workforce. Both are intertwined and both are steeped in manyethical issues. In this article, however, I will focus on two specific ethical issues related tofinancial compensation and equity in health care. To accomplish this purpose, I will firstdiscuss relevant background information and ethical tenets that frame the issues. I will thendiscuss the two ethical issues and suggest professional and managerial strategies to cope withthe issues.Background InformationMarket-Driven ForcesRestructuring of health care over the past decade has profoundly affected its methods of delivery and financing. This impetus for restructuring has had as its goal the "access to high-quality effective health care...available to all...."(Korniewicz & Palmer, 1997, p. 109); the authors call this goal the "preferable future" for nursing (1997, p. 109). This "preferablefuture," however, has been challenged by several factors, especially "a market-driven healthsystem whose defining characteristics are cost cutting, reduced utilization of services, andmaximization of revenues and return on investment"(Malone & Marullo, 1997, p. 1). The preceding culprit is often called managed care; mismanaged care is a more appropriate nameand excludes those managed care organizations that have decreased cost while increasingquality.Mismanged care is a hotbed for potential or real ethical issues. In 1995, the American NursesAssociation (ANA) published a brochure on "Managed Care: Challenges & Opportunities forNursing" that noted ethical issues such as lapses in the seamless and coordinated carepromised by managed care organizations, the too often unsafe decrease in the use of RNs,and the misuse of financial incentives that profits managed care organizations rather thanconsumers. In May 1996, the ANA published a "News Release" that highlighted a growing concern of Americans that quality of care was taking a back seat to "the bottom line." InOctober 1996, Canavan reported in "The American Nurse" about questionable ethical practices in managed care such as lack of full disclosure, gag rules, and compensation plans
that reward the withholding of nursing services. In the summer of 1997, Silva highlighted the ethics of consumer rights as mandated in the Managed Care Consumer Protection Act. One of these rights relates to financial compensation that does not adversly affect the health andwell-being of consumers. In sum, then, market-driven forces and financial incentives orcompensation are closely aligned and, although not always the case, too often have adverselyaffected health care.Health Care WorkforceAccording to Isaacs and Knickman(1997), today's health care workforce is the most rapidly growing part of the American labor market; it is 11 million strong and employs one out of every ten workers. This powerful workforce's largest group is its own 2 million plusregistered nurses.The vast majority of these nurses once comfortably employed in hospitals are now caught upin market-driven forces that at times seem to be beyond their control.The vast majority of these nurses once comfortably employed in hospitals are now caught upin market-driven forces that at times seem to be beyond their control. According to Hadley(1996), "...nurses need to prepare for the inevitable dislocation that will occur as the result of  hospital downsizing and other dramatic changes in the delivery of health services" (p. 6). Shecalls this challenge the "accepting [of] job insecurity" (p. 6).With job insecurity comes fear of job changes and losses. This fear is heightened by, amongothers, the increased hiring of unlicensed assistive personnel (UAPs) despite a lack of empirical outcomes that UAPs increase patient satisfaction or decrease cost. To complicatethe situation, the use of UAPs is generally unregulated, allowing employers to determine thestaff mix for health care services(Redman, 1998). If employers are driven only by cost containment, they may hire (and have hired) less expensive health providers to replaceregistered nurses. Again, market-driven forces are at work -- this time altering supply anddemand. The result is less demand for registered nurses and, thus, the possibility of decreasedand inequitable financial compensation for them.Financial Compensation and Ethical TenetsHealth care delivery systems, financial compensation, and ethical issues related to resourceallocation are intertwined because resources are ultimately finite. Therefore, principledethical methods for allocation of resources are needed at both the macroallocation (populationand groups) and the microallocation (individual) levels. When these preceding resourcesbecome scarce, rationing is also involved. The ethical tenets that best fit the relationshipsbetween scarce resource allocation and financial compensation are those derived fromutilitarian ethical theory and from ethical principles of justice.Utilitarian Ethical TheoryMany authors have summarized utilitarian ethical theory (e.g. Beauchamp & Childress, 1994;  Davis, Aroskar, Liaschenko, & Drought, 1997; Garrett, Baillie, & Garrett, 1998); however, the basic tenets remain the same and are usually based on the writings of the nineteenthcentury philosopher John Stuart Mill. The basic underlying tenets of Mill's ethical theory arerelated to the principle of utility and can be summarized as follows:First, the rightness or wrongness of an act depends on the consequences produced by the act.Second, the consequences produced by an act may cause either happiness (pleasure and theabsence of pain) or unhappiness (privation of pleasure and the presence of pain). Thus,utilitarianism is essentially a trade-off philosophy; one that maximizes good and minimizesharm in trade-off situations. Lastly, those acts whose consequences promote happiness tendto be right actions, whereas those acts whose consequences promote unhappiness tend to bewrong actions.(Silva, 1990, p. 23-24). When assessing consequences, philosophers tend to take one of two positions: (a) oneassesses the effect of the consequences on all persons affected by the act; or (b) one assesses
the effect of the consequences on those persons most affected by the act. However, the layperson's version of Mill's principle is often simply stated as "the greatest good for the greatestnumber."In relating the ethical principle of utility to financial compensation, it seems as if it would beto one's advantage to be "the greatest number."I submit that one of the most significant factors influencing many nurses' lack of adequatefinancial compensation is nurses' real or perceived powerlessness.Ironically, registered nurses are the greatest number in the American health care workforcebut do not receive the highest financial compensation (assuming such compensation would bea great good). Obviously, other factors besides large numbers are at work. I submit that oneof the most significant factors influencing many nurses' lack of adequate financialcompensation is nurses' real or perceived powerlessness. Nurses' powerlessness can occureasily in managed care or other health care organizations where thoughtless cost cutting andthe maximization of organizational profits at any price are the priorities. Such priorities,however, usually produce undesirable or harmful consequences both to nurses and to thepublic they serve and, ultimately, violate the "greatest good for the greatest number"principle.Ethical Principles of JusticeMany authors also have summarized ethical principles of justice (e.g., Beauchamp &Childress, 1994; Davis, Aroskar, Liaschenko, & Drought, 1997; Garrett, Baillie, & Garrett, 1998); however, the basic tenets remain the same. These tenets focus on justice as givingothers their due, justice as fairness, and equitable allocation or distribution of resources/scarce resources. According to Beauchamp and Childress(1994), justice can be defined as "fair, equitable, and appropriate treatment in light of what is due or owed topersons" (p. 327), and distributive justice can be defined as "fair, equitable, and appropriatedistribution in society determined by justified norms that structure the terms of socialcooperation" (p. 327). Put another way, distributive justice deals with the fair distribution of society's benefits and burdens. In addition to distributive justice, there are material principlesof justice that can help health care providers think through allocation of resources/scarceresource decisions. Examples include the following:To each person an equal shareTo each person according to needTo each person according to effortTo each person according to contributionTo each person according to meritTo each person according to free-market exchanges (Beauchamp & Childress, 1994, p. 330).Material principles of justice must be morally relevant and not capricious (e.g., to eachperson according to race).Finally, the philosopher John Rawls offers a creative view of justice. According to Rawls(1971), the following two principles encompass the essence of his theory of "justice as fairness:"First: each person is to have an equal right to the most extensive basic liberty compatible witha similar liberty for others.Second: social and economic inequalities are to be arranged so that they are both (a)reasonably expected to be to everyone's advantage, and (b) attached to positions and officesopen to all. (p. 60)What Rawls is saying is that inequalities can be morally justified within a society if they arefair; that is, some persons, corporations and so forth can have societal advantages if, and onlyif, these advantages benefit the least fortunate members of society such as the poor.In relating the ethical principles of justice to financial compensation, one begins to

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