Ethical issues in healthcare are common. Nearly every decision that’s made has ethical implications–for patients, for providers and for healthcare leaders.

Which issues impact hospital administrators and clinical leaders the most? Healthcare Briefings spoke to a panel of experts to get their view of the top ethical challenges in healthcare that are facing today’s leaders:

  1.  Balancing care quality and efficiency Many of the challenges facing the healthcare system in the future will be related to the overall challenge of balancing quality and safety with efficiency, said Cynda Hylton Rushton PhD, RN, the new Anne and George L. Bunting Professor of Clinical Ethics at Johns Hopkins University. “It raises a real question about whether the right values are driving our focus in our healthcare system,” she said. “Should efficiency be the driver?”
  2. Improving access to care Although the Affordable Care Act (ACA) was mostly left untouched by the sequester, the ongoing issue of providing everyone with access to basic medical care remains a concern. Philip Rosoff, MD, director of clinical ethics for Duke Hospital and Duke University School of Medicine, sees this lack of access as the country’s biggest ethical issue. “It’s shameful,” he said. “All the other stuff pales in comparison.” Gerard Magill, PhD, professor with the Center for Healthcare Ethics at Duquesne University, notes that there are still questions about the implementation of the healthcare reform law, as well as Medicaid expansion efforts in the states. Most ethicists believe that access to basic care is a hallmark of a civilized society, he said, and if many people still do not have access, “that is a problem.”
  3. Building and sustaining the healthcare workforce of the future As the baby boomer generation continues to age, more healthcare professionals will be needed to take care of this population–to manage chronic illnesses, coordinate care and provide many other services. But will there be enough competent, compassionate people who not only enter the healthcare workforce but remain in it to provide that care? Despite a recent influx of younger people into the nursing profession, for instance, many experts are forecasting a resurgence of the nursing shortage by the end of this decade–just when more nurses will be needed. “This is not just a supply issue,” said Rushton. “This is a sustainability issue. And one of the real threats to keeping the people we train in practice is having an ethical practice environment where they can actually practice with integrity, and where they are not constantly barraged with morally distressing situations that burn them out.”
  4. Addressing end-of-life issues Nancy Berlinger, PhD, a research scholar with the Hastings Center, noted that end-of-life issues will also grow in importance as the population ages. The entire decision-making process, as well as the financing that pays for end-of-life care, will be up for discussion as these issues affect more people. But that is the reward for the great leaps in life expectancy that were achieved in the 20th century, she said. “This is the ‘other shoe’ in the 21st century, the consequences of people living into their 90s,” she said. The Hastings Center will soon release a revised and expanded version of its 1987 guidelines on end-of-life decision-making and care; it will include resources for providers who want to learn how to have better conversations with each other and with patients and their families.
  5. Allocating limited medications and donor organs Will there be enough critical medications available to meet people’s needs in the future, and if not, what can be done about it? How will organs be allocated in the future, when they are often in short supply? Medication shortages often happen because there’s not enough economic incentive for manufacturers. For example, certain intravenous medications that are generics tend to be the ones that become scarce because there’s not much profit in making them, said Rosoff. “Until we fix some of the perverse incentives that we’ve built into the system for the creation and distribution of drugs in this country, I think it’s going to continue to happen,” he said. Although some advances have been made to encourage the reporting of drug shortages in an effort to reduce them, the Food and Drug Administration still expects shortages to occur in the future. According to clinical ethicist Katrina A. Bramstedt, PhD, the Affordable Care Act may help transplant candidates with coverage for certain necessary medications, such as immunosuppressants. “The bigger problem is the ongoing shortage of donor organs,” said Bramstedt, associate editor of the Journal of Bioethical Inquiry. “There are just not enough livers or deceased donor organs to meet the need. Here is where continued research, as well as more donations, would help.”

In addition to this list of five issues, ethicists acknowledge that other concerns will continue to develop, such as healthcare technology’s impact on communication policies, medical records and patient privacy.

But Rosoff maintains that access to care is the most significant ethical matter at present. The other issues are very important, but this one is at the top of his list.

“It must get fixed,” he said.