April 21, 2000

Grand Rounds explores medical center ethics

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Dr. John Sergent (right) served on a recent panel discussion of medical center ethics along with Dr. Harry Jacobson and Dr. Deborah German. (photo by Anne Rayner)

Grand Rounds explores medical center ethics

The questions were not softballs.

They were hard and they were well hit — sharp grounders and wicked line shots that could have easily taken a nasty hop.

And for the most part, the questions peppered at a panel of Vanderbilt University Medical Center officials at the recent Ethics Spring Grand Rounds were fielded with dexterity. They ran the gamut of ethical scenarios faced by a large academic medical center such as VUMC, from reconciling cost-reducing programs with investment in new buildings and facilities to the patenting of human disease genes for financial gain.

The program, sponsored by the VUMC Ethics Committee, was titled "Medical Center Ethics: An Oxymoron? Tough Questions for a Panel of Experts." Dr. Frank H. Boehm, professor of Obstetrics and Gynecology, director of Maternal/Fetal Medicine and chair of the Ethics Committee, served as moderator for the question-and-answer session.

The panel of experts included Dr. Harry R. Jacobson, vice chancellor for Health Affairs; Dr. Deborah C. German, senior associate dean for Medical Education; Mark L. Penkhus, executive director and chief executive officer of Vanderbilt University Hospital; Dr. John S. Sergent, chief medical officer of Vanderbilt Medical Group; and Richard M. Zaner, Ph.D., Ann Geddes Stahlman Professor of Medical Ethics and director of the Center for Clinical and Research Ethics.

Most of the questions were related in some way to money — where the institution gets it and how decisions are made about how and where it's spent.

The questions came from staff, faculty and members of the Ethics Committee and were broken down into four main groups; cost issues, provider issues, patient issues, and institutional responsibility.

Panelists did not see the questions beforehand.

The following is a sampling of some of the ethical questions posed and the panelists' responses.

How do we reconcile our mission of caring and healing and still balance the 'bottom line' of the medical center?

Jacobson: "The simple answer is that no margins means no mission.

“There's a lot of truth to that because in addition to caring and healing, this institution also is dedicated to education and research.

"We have several noble missions at Vanderbilt, and to do all of them well, not just one, we have to have a positive bottom line. That is everyone's goal and everyone's responsibility."

There is a continuing emphasis on utilization review and sophisticated ways of tracking test ordering trends are available. How can we espouse treating each patient as an individual and yet promote standardization of practice?

Sergent: "Whether we want to acknowledge it or not, in the world of health care unnecessary testing goes on and it's not just expensive, it's dangerous. Standards of practice are guidelines, and in this country only 60 percent of patients are cared for according to proper guidelines, and there is no justification for the diversity of testing and treatment practices.

"Yes, each patient is different, but with large enough numbers of patients you can make comparisons. With utilization review and tracking we are saying that we are going to be accountable for the cost of the care we provide."

How does VUMC justify spending millions of dollars on new buildings while crying 'poor' when it comes to patient care?

Penkhus: "We spend millions on new buildings because that's what's necessary to not just compete in this market, but to be dominant in this market. These buildings will help generate the funds that will allow the medical center to aggressively pursue its missions of patient care, education and research.

"We're not crying poor, we're crying for sound fiscal management because we're trying to balance being efficient with attracting new faculty and planning for targeted growth."

How are decisions made about who gets laid off around here?

Jacobson: "Individual decisions were made on a case-by-case basis in the midst of our ongoing operational improvement efforts. In comparison with other academic medical centers — and factoring in the types and severity of cases we see — we were way off in number of employees.

“Most of the corrections were handled through attrition and we are getting to the size we need to be to remain competitive. I think we're through most of the pain.

"As far as the new buildings and programs are concerned I think some pieces of the institution's infrastructure — such as research and financial oversight — were underdeveloped, and that's where much of our investment is going.

Is it ethical to encourage the patenting of human genes for financial rewards?

Jacobson: "Free enterprise drives technology transfer the same way it has for the development of other drugs and devices used for human application.

“Nearly 75 percent of our budget and employees go toward delivering care, and we get paid for that. Technology transfer is the same — in addition to caring for patients and getting paid, we're taking the products of our research and getting paid.

"Whether it's fees for providing care or revenues generated by technology transfer, the ethical challenges are the same."