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Ethical catch-22
The prevalence of ethical catch-22s is a long-standing
concern for all nurses, and has prompted the periodic
update of nurse ethics guidelines through the American
Nurses Association. The most recent changes occurred
in 2001, when nursing’s ethical responsibility
to patient efficacy in research and management was codified.
“The earlier versions of the code were more geared
toward staff nurses,” said Laurie Badzek, JD,
RN, director of ethics and human rights at the ANA and
a professor in the school of nursing at West Virginia
University. “But when we redid the code, we made
sure it covered a broader base of nurses. And when you
look at that document, it doesn’t necessarily
speak to any specific situations.”
Bell culled numerous examples of utilization review
nurses caught between their ethical leanings for patient
care and organizational goals. The uninsured wife of
a covered cardiac patient refuses to let the home health
care team treat him unless they give her care, too.
Sometimes, it’s the pressure to do something illegal,
such as when an employer asks for the denial of a workers’
compensation claim not because a worker is faking an
injury, but because the worker is a “malingerer”
on the job.
In ethics, “we tend to think about the big questions
like abortion, genetic engineering,” Bell said.
“Perhaps what is more important to nurses are
the ethics of things that happen day to day.”
But without an organizational code of ethics, according
to Bell’s report, utilization review nurses are
left to rely on professional ethics codes and personal
beliefs. Frequently, those two issues might collide
in case management, Bell said. When utilization review
nurses are “asked to make a decision based not
on this individual patient, but based on the average
patient or the patient in general, that’s very
difficult for nurses to do,” she said.
“It’s a direct conflict between those two
because you have to take a population point of view
if you’re going to use protocols,” Bell
said, “and that’s different from taking
an individual point of view.
Different outlooks
Many utilization review nurses adopt the view that
the nurse and patients have different outlooks. One
respondent to Bell’s study noted that patients
want individual attention to medical needs, but the
utilization review nurse “has a different paradigm.
The benefit is for all, not just for one. The nurse
thinks about the patient, the provider, the employer,
the insurance company, etc.”
The need to make such judgments stirs debate on how
ethical guidelines for case management can be improved.
Nurse administrators within managed care organizations
are encouraged to develop structured ethical decision-making
support for nurse utilization reviewers, according to
experts.
But there are apparent signs in recent years that the
ethics concerns of utilization review nurses are being
considered by their employers.
Another study by Bell showed a majority of surveyed
utilization review nurses are not being used as “technical
resources” to justify claim denials in managed
care organizations, and that most utilization review
nurses still base a majority of their decisions on care-based
criteria.
“We have had no [national] discussion of the
real need to have rationing or maybe cutting down on
excess medical care when we have so many people who
don’t have any sort of good medical insurance
coverage,” Bell said. “So, in lieu of having
some sort of public debate, it’s nice to have
a nurse making those decisions, because at the base
of nursing is this idea that we will be benefiting the
patient.”
Contact
Glen Fest at glenf@nurseweek.com.
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