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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.