What are the effects of economic and structural constraints in hospitals on patient care? How can financial targets be reconciled with the ethical requirements of medicine and healthcare?
These were among the questions which the German Ethics Council discussed with experts from various disciplines, with medical and healthcare practitioners and with more than 200 visitors in Dresden's Hygiene-Museum (Museum of Hygiene) last Wednesday.
The aim of the event was to bring together ethics and economics on the basis of a differentiated analysis, in order to develop possible solutions for guaranteeing good patient-oriented medical, nursing and psychosocial care under conditions of limited financial resources. For, in the words of the Chairman of the German Ethics Council, Christiane Woopen, 'the patient is the purpose of healthcare, not a means to maximize profits'.
An account of economic and structural changes in hospitals since the 1970s was given by Michael Simon from the University of Applied Sciences and Arts in Hanover. Irmtraut Gürkan from the Heidelberg University Hospital analysed the problems from an economic point of view. Brief lectures examining the problems and their consequences from the perspective of doctors, carers, hospital operators and patients were given by Arved Weimann from Leipzig's St George's Hospital, Meike Friedrichs from the Heidelberg University Hospital, Magdalene Günther of the AWO-Gesundheitsdienste (Welfare for Workers Health Services) in Hanover and Carola Sraier of the Unabhängige Patientenberatung Deutschland (Independent Patient Counselling in Germany). Giovanni Maio from the University of Freiburg and Nikola Biller-Andorno from the University of Zurich reflected on the ethical challenges in day-to-day hospital routine.
The closing panel discussion was dedicated to possible concepts for a 'healthy' hospital. Ethics Council member Eckhard Nagel discussed solutions with Lutz Stroppe, State Secretary of the Federal Ministry of Health, Andrea Lemke of the Evangelisches Waldkrankenhaus Berlin-Spandau (Protestant Forest Hospital, Berlin Spandau), Klaus Lieb from the University Medical Centre Mainz, Georg Marckmann from the Ludwig Maximilian University of Munich, Elisabeth Steinhagen-Thiessen, member of the German Ethics Council, and retired hospital manager, Rüdiger Strehl.
One aspect which emerged as a key problem in patient care was a funding system that is geared primarily towards economic efficiency with the result that the well-being of patients and the quality of care are increasingly pushed into the background. This situation causes both under- and over-provision. Increased workloads, process optimization and outsourcing have already been exhausted in many hospitals as methods of raising efficiency reserves, without any guarantee that those hospitals will survive. Many hospital employees internalize the increased workloads and the ways in which medical and nursing procedures are reshaped by financial factors, and regard it as a personal failing to no longer to be able to provide for patients at a level that is actually considered professionally required.
The need was expressed for the creation of a quality-oriented and sustainable funding system which facilitates medical decisions geared towards patients' well-being, rather than penalizing such decisions economically. The way in which psychosocial variables and patient reports could be recorded as part of this remains to be discussed. Incentives should be provided with a focus on good relationships in medicine and linked to concrete objectives. Economics on the one hand and medical and nursing competence on the other hand should work together on an equal footing in hospital management. Finally, there was a general consensus that a return to the old structures was neither possible nor desirable.
It is, however, imperative that there be a zone of medical activity that is kept free of economic constraint, as Ethics Council member Thomas Heinemann stressed at the close of the conference. Hospitals should reflect on their historic roots as social institutions.
The German Ethics Council will discuss ways of developing the topic of the conference and will compile recommendations.