Home Health Care and Inpatient Loyalty
Brown City Hospital had just received notice of the funding of an experimental
program in integrated geriatric health care. It was an ingenious proposal
designed in part to provide additional funds for the desperately understaffed
geriatrics program. The thesis of the project was that geriatric patients have a
complex set of medical, social, and psychological problems requiring integrated
attention by physicians, dentists, nurses, pharmacists, allied health providers,
and social workers, all of whom need special skills and aptitude to deal with
the elderly. Until now, geriatric patients had to shift for themselves, moving
in the hospital from department to department to meet their needs. This was
particularly difficult for the elderly. The grant was considered both an
experiment providing health care for geriatric patients and a new source of
funding for medical services.
The senior staff of the geriatric program included geriatric specialists from
psychiatry, internal medicine, surgery, dentistry, pharmacy, nursing, allied
health, and public health, in addition to personnel from social work. They were
meeting to begin planning the details of the new service. Brown City Hospital
served an inner-city community of 300,000. Since geriatric patients presently in
the hospital were being cared for by separate clinics, it was difficult to
estimate the size of the population of patients actually being served who would
qualify for the new program. It was clear, however, from waits of four to six
weeks for appointments that the present patient population could be served much
more effectively.
A major policy problem arose during the meeting, Dr. Joel Winters, an internist,
Dr. Roberta Hays, a psychiatrist, and Dr. Richard Green, a dentist advocated a
new geriatric clinic at the hospital. They argued that their first
responsibility was to meet the needs of those who were already using the
hospital’s services. They claimed that those who had sought out the hospital
were likely to be in the greatest need. More important, they held that a special
obligation existed to improve the health care of those who were already in the
Brown City Hospital patient population.
Dr. Martin Dover, the public health epidemiologist, and Ms. Wilma Ryder, the
social worker, Dr. Norma Branch, a nurse, Ms. Wilma Blue, a physical therapist,
and Dr. Robert Smith, a pharmacist defended another approach. They felt that the
program, to be truly innovative, must emphasize home health care. They argued
that there was even greater medical need among those who were not yet in the
hospital’s patient population, who were too sick or too immobile to come to the
hospital for help. They made another argument, however, that extended beyond the
empirical question of who could be helped the most. They argued that because it
was a city hospital, they had an obligation to all the elderly sick in the
hospital’s catchment area. Their special obligation was not to those who were
already getting care from the hospital but to those who were not yet being
served. They conceded that home health care might be less efficient. Much time
of medical personnel would be spent on travel. They defended the program,
however, first by arguing that the quality of care would be better in the
patient’s home, and second by maintaining that home care, even if less
efficient, was owed as special duty to those not now getting medical attention.
Questions:
What is the primary area of
disagreement between the two groups?
What are the expected consequences,
which drive the moral arguments? Consider both courses of action.
Do the represented disciplines show
bias regarding care being provided in a hospital setting vs. the familial
setting?
Does a conflict of duty exist between
the two groups? (Defending the traditional physician ethic of patient benefit
vs. special duty to the physicianless.)
Consider the principle of justice and
fairness in your deliberations.