Rethinking patient-health care provider relations: An ethical perspective

- Batami Sadan, Ph.D.
Kovens Health Systems Management Center of the Leon Recannati Graduate School of Business Administration,
Tel Aviv University
1 Alterman st., Tel Aviv, Israel 69415
Email: sadanba@netvision.net.il
Eubios Journal of Asian and International Bioethics 11 (2001), 136-141.

Abstract
The conflict between the individual's needs and rights and society's capability and obligation to guarantee them is clearly manifest in the health arena. Decisions for allocating limited resources are made by health system officers and medical teams, while the patients' expectations are not based on economic considerations. This conflict is exacerbated by the prevailing gap in knowledge and information between patients and caregivers and by limitations of the patient's scope of choice.

Ethical principles should provide the necessary guidelines of behavior in these states of conflict. Neither of two opposing philosophical approaches, collectivism and individualism is suitable to provide guidelines for dealing with the complex dynamics within these conflicts, while the systemic ethical approach to morality/ethics is particularly suitable to do so. It provides a framework for the pursuit of the Socratic ideal of the "good individual in a good society". We present the systemic approach and demonstrate its suitability for resolving an exemplary health care-related conflict.

Key Words: Health care system, health care provider-patient relations, moral principles, patient's autonomy, systemic approach to morality.

Introduction
Asymmetry is one of the most conspicuous features that characterize the relationships between patients and the medical institution [1-7]. In effect, patients must not only contend with the physician who treats them, but with an entire social institution, with its ethical traditions, its accepted practices and its vested interests. While patients may be the proprietors of their body, and while they may have rights to express their medical preferences, the knowledge and skills to treat them reside with the physician and the medical establishment. Constraints imposed by society and by the particular medical organization within which they operate will determine which therapeutic intervention they will offer [8-17]. Asymmetry, inevitable in such a system, results in limitation of the patient's scope of choice. In a situation where partners have conflicting interests, ethical principles should provide the guidelines for them to reach a just modus vivendi.

We adhere to the view that values and morals, in addition to knowledge, guide people in their day-to-day actions ¾ particularly deliberate ones ¾ and rightly so. Furthermore, our proposed framework of relations between the various parties in the health care context is based on our belief that the world of values and the world of needs are not separate entities. Such an approach can not only contribute to the discussion of what constitutes medical ethics, it can also assist in resolving actual conflicts in this area of human conduct.

The current review is based on Mario Bunge's ontological and ethical approach [18,19] which provides scientifically and ontologically based ethics in which morals and facts co-exist. We will present the complexity of the relationships in the health care context through the systemic approach and present one exemplary case of an ethical dilemma in medicine. We will analyze the conflict demonstrated by this case with the aid of the systemic approach. We will demonstrate how this approach can more competently analyze and provide guidelines in complex conflicts since it provides the unique possibility of relating the relationships and responsibilities of each party ¾ in addition to dealing with the issues at the individual level of the two main actors ¾ represented by four 'principles' of medical ethics [20,21] as well as with the physician's Hippocratic commitments to the patient.

The need for a new ethical approach in the changing world of medicine has been recently discussed to a considerable extent [4-7,22,23]. We propose that Bunge's systemic approach is particularly suitable to examine the complex and often difficult situations of the issues involved.

On Values and Morals
Moral theories present an opinion about what is 'good' or 'valuable' in the properties we wish to effectuate in our own actions and in those of society in general. For example, the theory of classical utilitarianism maintains that the only property that matters is happiness or pleasure, while other theories claim that only human freedom is important, etc. The second component found in every moral theory is described as the 'theory of right'. As opposed to advocating which properties are valuable, it pertains to what individuals and institutional agents should do by way of responding to valuable properties [24].

Values
Values are an individual's evaluation (value judgment) of events, processes or situations. In their simplest form, they are described as 'good or bad' or 'better or worse'. They do not exist in and of themselves, but rather emerge from our needs and desires, and we tend to evaluate most of the issues we deal with and most of the actions which affect us according to them. Needs and desires and their corresponding values are either individual or social. Individual values can be further divided into biological and psychological ones.

Sometimes, an individual's value could represent a threat to society as a whole. Reproduction of the species is an example of this kind of conflict: in certain societies at certain times (e.g., following wars or plagues), the individual's value of reproduction is also considered a socio-value. But, in countries that suffer from overpopulation, the individual's value can be a threat to the very viability of these societies.

A psycho-value is evaluated subjectively. It is often in conflict with objective health values, such as the gratification from smoking versus the known dangers of nicotine to health: it has both a bio-value (detrimental to health) and a psycho-value to the smoker.

Some values which apply to an individual's needs are personal, some are social and others are systemic, i.e., they apply to social systems. Friendship is an individual value, as is doing good deeds. Health care and environmental protection systems are systemic socio-values that can apply to a region (i.e., a system of states) or to a single state.

Value conflicts
All human beings face internal and external (interpersonal or intergroup) value conflicts which arise either from holding mutually incompatible values or from the inability to equally distribute the limited resources [18]. Indeed, if there were one single moral value which overweighed all others, many value conflicts would be eliminated.

History has taught us that conflicts should be resolved through some kind of compromise, a condition wherein neither value in question is either fully realized or fully sacrificed, and that compromise is preferable to demise. According to this historical model [18], nothing would be pursued to its maximum or minimum. The course to be chosen depends on the goals and means. For instance, every company faces a conflict between profit and service. If the company is to survive, it will strive for a compromise, combining submaximal profit and acceptable service.

Achieving a compromise in health care is more complex. The Hippocratic Oath confers professional standards on physicians which mandate them to provide their patients with the best possible treatment available. However, physicians work under constraints, e. g., limited resources, which do not always allow them to observe this standard for each and every one of their patients. Here, the compromise is unlike that which a company can chose ¾ less profit for better service ¾ but rather a compromise that could well be of far-reaching significance.

Morals
Human social behavior is constrained by environmental, economic, and social constraints. Social behavior under these constraints is guided by man-made, thus changeable, norms or rules. Norms are legal or moral or both, and specify that a certain action is morally right or wrong, with the aim of helping individuals to attain their needs and desires within the constraints of a given society. Individuals acquire these norms by education, implicit or explicit, and through experience.

Moral rights and duties form moral codes, and systems of moral codes act as devices for regulating social behavior. Thus, a moral code is defined as a system of human-made moral norms which specify the basic rights and duties of people in a given society in a given order of priority.

Spheres of moralities
Individuals, not society, create norms. However, while every moral norm concerns the behavior of an individual, morality is a social matter. By their being intended to resolve conflicts between the interest of one individual and those of others, norms form rules of social behavior.

Members of a society have rights and duties towards that society as a whole (the state) and with other social systems within it (e.g., the workplace). Herein lies the potential for conflicts between the individual's private rights and social duties. It is, therefore, useful to distinguish between those two and other moral spheres. A typical distinction is the following [18]:

a. Personal (or private morality), which can be defined as the set of norms which concern one's private life and inter-personal relations. Here, some morals even cross (though are not independent of) societies and cultures, e.g. the duty to refrain from murder.

b. Social (or public) morality is a set of norms (e.g., social justice) concerning the relations between the individual and society (e.g., community, government). These can be further divided into local (e.g., paying taxes) and universal (e.g., protection of the environment) norms.

c. Professional morality is the set of norms, which guide a particular profession (e.g., for the medical profession, one of these would be not to cause harm).

The organizational sphere
Among the social systems to which an individual can be related and be consequently subject to duties, rights and moral conflicts, of particular interest to us are organizations, such as the workplace, the providers of services, and particularly for the current study, the medical organization represented by the hospital. In the workplace, the conflicts may be difficult to resolve and even to cope with since the values (hence the rights and duties) imposed by an organization, such as the values of its shareholders and directors (e.g., maximizing profits), often contradict important rights of the individual employee or client. Whereas most of the social rights and duties of the individual in a society (or state), as a whole, are defined by the constitution and by law, this is not the case with regard to individuals and organizations.

Modern health care systems and organizations are undergoing enormous changes due to the economic policy of privatization. These changes, however, have not been supported by appropriate changes or reforms of moral norms. For example, physicians are often being compelled by hospital economic management to opt for less expensive ¾ and possibly less effective ¾ medications. For the purpose of analyzing and setting up guidelines for the moral conflicts arising from complex situations and contradicting moral values, we propose that the "systemic" approach provides a superior theoretical framework.

Individualism and Collectivism
Since members of society have rights and obligations to society and to social systems within it, a situation emerges which obviously embodies potential conflicts between individuals' rights and their social obligations.

Individualism: ontological and methodological aspects
Advocates of this philosophical approach focus on the individuals and reject social contracts and social systems, or, alternatively, claim that one can refer to the collective of the individuals as an aggregate of the individuals and their activities.

Individualism: the shortcomings
Individualism cannot explain social structures (e.g., division of labor, production) nor the emergence of social systems (multi-national organizations such as the UN, IBM, etc.) and the dynamics of social change (e.g., war, social reforms, etc.). It does not relate to the problems of the individual-to-society/society-to-individual relations.

Collectivism: ontological and methodological aspects
The collectivist believes that the rights and obligations of individuals are decreed by the desires or needs of the whole. Social systems behave as wholes. For example, an educational establishment (e.g., a school) or an economic institution (e.g., a factory) have properties of the whole, and their behavior is not just as an aggregate of the behaviors of its individuals but an integration of those behaviors within the system, and of that system with other systems.

Collectivism: the shortcomings
There is no system without components. Social systems are networks of interconnected persons, sub-systems and artifacts.

Ethics in individualism and collectivism
The prevailing value systems in Western society are derived from the two extremes, individualism and collectivism. In terms of ethics, the former supports a morality that places private interests before the interests of the public, whereas collectivism sacrifices the individual to the whole. Individualists admit only personal values, which they tend to regard as both subjective and permanent, while denying the existence of social values. The collectivists maintain that society is the source and support of all values, hence they tend to deny the validity of individual (biological or psychological) values. The distinguishing features of these approaches can be summarized as follows:

Individualistic ethics:

Individuals are or ought to be autonomous, i.e., fully self-determined.

Individual values, particularly liberty, are higher than social values, particularly justice.

Individual rights take precedence over social duties.

Society is only a means for the protection of individual rights.

Morals and the law are made for the individual.

Whenever there is a conflict between individual and social values, the former take precedence [18].
Holistic (collectivism) ethics:

Individuals are heterogamous, i.e., other-determined.

Social values, particularly stability, are higher than individual values, particularly liberty.

Duties toward social organizations take precedence over duties toward individuals, and these take precedence over individual rights.

The individual is only a means for society.

Morals and law are for society.

Whenever there is conflict between individual and social values, the latter are to prevail.'²⁸

The Systemic Approach

Systemic ethics

Individual and social values determine each other.

Individuals have rights (e.g., enjoying well-being) and duties (e.g.. helping others to live).

Individuals are partly autonomous and partly heterogamous.

Rights imply duties and the converse.

The only legitimate function of a social system is to promote the well-being of its members or those of other social systems, without depriving anyone of his/her basic needs.

Social norms and laws are for the individual in society.

Private and social values are inseparable and none is superior to the other [18].

The differences between systemic ethics and its rival philosophies are perhaps best seen when applied to a specific problem, such as , for example, 'accountability'. Individualists hold that only individuals can be blamed or credited for whatever they do, and collectivists blame the 'system'. From a systemist viewpoint, the individualists are correct in blaming or crediting individuals for whatever they are responsible, but they are wrong in overlooking the fact that every individual is socially conditioned, at least in part, to behave rightly or wrongly. The collectivist is correct in blaming or crediting the 'system', but the systemist credits or blames the individual in society, and proposes to reform both the individual and his/her society through collective action, which is nothing short of orchestrated individual action.

Systemism is only an approach and not a single 'systems theory' that can explain all social phenomena. As such, it consists of certain ontological and methodological hypotheses. Its framework, however, can be filled with specific methods, data, models and theories concerning a particular concrete system. The same holds for the application of systemism to the design (synthesis) and reform (change) of social systems ('social technology'), for example, of health care systems.

The following sections will apply systemism to health care, first by describing the health care system, and then by analyzing an event which is representative of an ethical dilemma.

Society

Health Care System

People

HCO**

The Patient Org. Subsystem

HMO*

The Individual HCP***

Medical

Profession

Figure 1: Composition and interaction between systems in health care provision

*HMO - Health care Management Organization (e.g. health care insurance company)

**HCO Health care Organization (e.g. hospital)

***HCP - Health care Provider (e.g. physician)

The Complex Structure of the Health Care System
Figure 1 represents the various relations existing in that sub-system of society relevant to the health care context. It also illustrates the interaction between the principal players, the patient and the individual health care provider (indicated by black circles). Those two are just part of a larger, more complex structure of relationships among a large number of participants. The complexity of this relationship stems not only from the number of participants, but also from the fact that the goals and morals of each of the parties differ and are often in contradiction to one another.

The two principal actors
Patients' health services and individual health care providers are directly influenced by five essential elements, which affect both the recipient and provider.

Society
This body is responsible for the policy of health care provision, of resource allocation, public health promotion, and health legislation, such as the Patients Rights Law, the National Health Law, etc.

Health care system
The system controls the availability of health services, practices and standards of physicians and other medical treatment providers, as well as the existence of disciplinary and ethics committees, a policy of approving experiments on humans, a policy of approving use of new drugs, and others.

Medical profession
This organization is responsible for professional ethics, behavioral norms, skills, standards, the effectiveness of disciplinary and ethics committees, and others.

Health care organization
A health care organization is responsible for the procedures and practices conducted within it in fields such as service, quality, ethics, competition, and others.

Health care organization subsystem (medical ward, clinic, laboratory, etc.)
Such a subsystem is responsible for the procedures and practices of the medical department, the standard of service it provides, the standard of the service it receives from other service departments, such as laboratories, the size and skills of the treating team and others.

If the health care system sets as its major value the provision of the best possible medical treatment for a patient, then it can be expected to operate and allocate resources in a manner that is different from one that operates expressly for profit.

The values of the individuals who operate under the various types of systems were earlier classified into the four moral spheres of personal, professional, organizational and social. The actions of a physician working in a specific medical department in a hospital are influenced by his/her own personal values (personal sphere), the values of the patient, as expressed during the physician-patient encounter (personal sphere), the values by which the physician is bound on the professional level (professional sphere), the values derived from the goals of the medical establishment and the department in which the physician works (organizational sphere), as well as the values and goals of the society of which both the physician and the patient are members (social sphere).

The rights and duties (rules of conduct) of each individual are derived from different values which emanate from these different moral spheres and herein lie the conflicts. Furthermore, the fact that the values and the morals of the physicians are derived from their own personal values, their professional values, their organizational values and the social values of their society plays an important role in the lack of clarity of which stand to take in any given conflict.

The systemic approach to ethics provides a way of combining personal rights with professional, organizational and civic duties in a manner that reduces the potential for conflict.

A good example of such ethical dilemmas appeared in the Israeli press. It illustrates how the systemic approach, which takes in account the complexity of the relationships in the health care system as well as the interaction between the entities involved and their responsibilities, competently assigns the responsibility for carrying out necessary changes to the appropriate parties.

Case In Point: Recycling Balloons for Heart Catheterizations
An Israeli newspaper published the findings of a study into public hospitals that recycle the use of thousands of balloons for heart catheterization, against the manufacturer's instructions. Despite the warning on the balloon's wrapper that states unequivocally that it should not be re-sterilized, financial considerations took precedent: a new balloon costs about $600 and sterilizing balloons for re-use saves millions of Shekel annually. The head of one catheterization unit claimed that balloon recycling does not endanger the life of the patient, in direct contradiction to the opinions of specialists that a rejuvenated balloon is rougher (possibly causing damage to the artery), its penetration is more difficult and that it is less effective than a new balloon. Used balloons also have more of a tendency to burst when they are pumped up to open the artery. Although this in itself is not dangerous to the patient, changing the balloon lengthens catheterization time, and since catheterization involves the use of an X-ray camera, lengthening the procedure increases the amount of cancerous radiation to which the patient and the medical team are exposed.

The Conflict as Viewed and Resolved by the Systemic Approach
At the personal level, this case shows a lack of consideration of the patient's autonomy. The action of a catheterization physician who obtains the signature of the patient on an informed consent form but fails to inform the patient that he/she will be treated with recycled balloons, and expose him/her to additional risks, does not observe fundamental ethical principles which every physician swears to uphold when taking the Hippocratic Oath. In this case, the law (i.e., the Israeli Patient's Rights Law) will also point an accusing finger at the physician. But should it be the physician who bears the full brunt of the responsibility? After all, the physician is restricted to function within the boundaries of and according to the dictates of the policies of the organization which employs him/her.

At the organizational level, it would be extraordinary for a medical organization to actually instruct its physicians to act against accepted medical norms. In the event that the medical institution believes that it is necessary to revise standards, there are appropriate channels for presenting its case and proposing such a revision.

At the social level, if the health system agrees to a revision in standards, hopefully after having been convinced that the public will not be harmed by it, the new policy should be publicized and thus be made known to potential patients, to medical insurance companies and to the financing bodies (e.g., health funds). As long as the current standards require the use of new balloons, the health system must not remain silent in the wake of violations of accepted medial standards. The medical institution must be made answerable for its actions, even to the point of considering revoking licenses.

At the professional level, a professional medical organization can be expected to stipulate its professional ethical codes and standards, and to protect the individual physician in the event that the organization places him or her in an ethical conflict of behavioral norms. In the case of recycling catheterization balloons, the physician of that specific medical institution should have broached his/her professional organization, which should have defended the physician's right to observe accepted medical standards and to stand by any physician who refuses to comply with an institutional decision, which is against these established standards.

Similar issues of conflict relating to the depletion of resources vis a vis maintaining standards of quality of care are not lacking. The following are a few examples retrieved from the local press.

Physicians employed by one of the sick funds in Israel receive bonuses for economizing on patients' prescriptions and treatments. Some of them are vigorously opposed to this policy, calling it "unethical" in possibly clouding the physician's judgment in making choices.

Physicians were instructed by a sick fund to change to less expensive medication for heart patients who are already well balanced by their current medication. Some objected to risking their patients to possible untoward effects of alterations in their medications.

A woman has undergone major surgery and it is the policy of her health insurance company that patients be released after a certain number of days following such an operation, but it is her doctor's opinion that she should remain longer in the hospital. The conflict between the health fund and the health care provider may impinge on her welfare.

These examples highlight the superiority of the systemic approach in providing guidelines that take into consideration the values and needs of all the parties involved in the conflict.

Discussion and Conclusion
The contemporary health system is a complex one under pressure to cope with a demand for services that is larger than the supply, with limited funds, with ever-changing technology, and with extremely intricate human situations. There are no guidelines when benefiting one patient should come at the expense of the interests of another. More problematic is the lack of clarity of moral goals within a system. Providing quality health care with accountability challenges the traditional Hippocratic ethics of the clinician [6,22]. Accountability entails the procedures and processes by which one party justifies and takes responsibility for its activities [5]. Who are the parties that should be held accountable? By whom? What are the issues for which these parties are held accountable? What are the standards for accountability [5]? I believe that medical ethics should be the basis for the guidelines to all of these questions. The individualistic approach fails to recognize issues and conflicts of individuals to society or society to individual. The collectivist approach fails to recognize the individual, with his/her values and personal wishes and sacrifices the individual to the whole. The most appropriate approach, therefore, is the one that accepts all the parties as units: individuals, groups, professionals, organizations and society as a whole, and the one that accepts the fact that there do exist conflicts in values, desires and behavioral norms, and tries to assign the responsibility appropriately. I contend that the systemic approach is the one of choice: it has the capability of guiding the behavior in conflicts by requiring all the parties involved to assume responsibility and be accountable for procedures within the system. Furthermore, disclosure of information from within its midst to the public at large, will, in our opinion, contribute much to improve the relationships between the parties.

'What should be disclosed and why?' asked Douglas F. Levinson in his article 'Toward full disclosure of referral restrictions and financial incentives by prepaid health plans' [25]. He was mainly concerned that insured patients be provided with information on restrictions in the choice of service, incentives and disincentives to physicians and medical institutions with regard to lack or overuse of certain medical procedures.

I believe that further research into the effect and contribution of the systemic approach, as described in this article, is warranted for understanding the complexity of the role of ethics in the health system and the distribution of responsibility between all the elements that play a role in medical treatment. There is also need to extend our knowledge on the importance of the disclosure of information, not only within the framework of the informed consent procedure between physician and patient, but also in its wider form, to include financial, ethical and logistic aspects. It would also be worthwhile to examine the repercussions of these issues on the quality of care and ethical conduct of all parties involved in the health system.

Acknowledgment
I wish to express my gratitude to my tutor, Dr. Jacob Steif, who was a great influence to me during my Ph.D. studies and on the writing of my dissertation. In particular, I thank him for our lengthy and in-depth discussions on the subject of health ethics, during which he introduced me to the philosophy of Mario Bunge, a philosophical approach, which provided the ethical and methodological basis for my work.

This paper reflects the opinion of the author alone and not the institution where the work was conducted nor the individuals whose contributions are acknowledged.

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