We believe the ethical obligations of health care networks are under discussed compared to other issues relating to such networks. The point is that even when particular interventions (for this paper, we will consider creation of networks) are suggested to be beneficial, they need to be justified in the particular context in which they will be implemented. A recent article raised the provocative question ‘Does quality improvement improve quality?’.
The uncritical transplantation of quality improvement interventions is thus always a risky undertaking. There is no guarantee, however, that such interventions work in every context.
Interventions, such as the creation of networks, might work to improve quality in a particular context when particular conditions apply. Second, there is debate on what we can learn from concrete examples of quality improvement. It is increasingly being suggested that ‘quality of care’ is an inherently normative, rather than a descriptive, concept and is thus far from uncontroversial. First, there are issues with the very concept itself. What counts as quality improvement and how this should be measured is a topic of much debate. Likewise, increasing quality of care does not guarantee ethical justifiability. This means it is possible that a particular for-profit hospital or HCN might fail to offer basic care to patients on the grounds that it is not profitable, or they might offer it at an unfairly high price to guarantee its profitability. A 2005 study showed that for-profit hospitals are less likely than not-for-profit hospitals to offer care that promises less potential profit for the institutions. A market-driven HCN could well be perfectly economically efficient but ethically unjust in failing to provide basic care for those worse off. Economic efficiency, for example, can come at an ethical cost. However, the mere fact that HCNs may be beneficial in particular respects and particular contexts does not automatically mean they are always ethically justified. Hopes are high for these collaborations and health care networks, which, as studies suggest, could increase economic efficiency and lead to improved quality of medical care. These changes are caused by many factors, including an ageing population and an increasing cost of the welfare system, resulting in medical resources becoming scarcer. Whereas traditionally, individual health care institutions formed the cornerstone of medical care provision, focus is increasingly shifting towards interorganizational collaboration, integrated care, and health care networks (HCNs). Health care organization is entering a new age. Health care networks raise new and pressing ethical issues and we are in need of a framework for assessing how and when such networks are justified. Such networks are the topic of empirical debate, but more attention should be given to the ethical aspects. Currently many hopes ride on integrated care and broad health care networks. Conclusionsįaced with daunting challenges, the health care system is changing rapidly. Networks that fail to meet any of these conditions are suspect and cannot be justified ethically. Finally, the principle of autonomy is translated into a specific obligation to promote and respect patient choice. The principle of nonmaleficence implies an obligation to guarantee patient safety, whereas the principle of beneficence implies an obligation for health care networks to guarantee continuity of care in all its dimensions. Based on the principle of justice, health care networks have an ethical duty to provide just and fair access for all patients and to be transparent to patients about how access is regulated. Using the classic four principles of biomedical ethics (justice, nonmaleficence, beneficence and autonomy) it is possible to identify specific ethical duties. We argue that a business ethics approach to ethical obligations for health care networks, is problematic and we propose to opt for a patient perspective. Due to their often amorphous and complex structure, collective responsibility and accountability may increase while individual responsibility goes down.
A relevant question that remains is what ethical obligations or duties one can ascribe to these networks especially because networks involve many risks. However, this does not automatically mean they are always ethically justified. Much hope is set on such networks which have been argued to improve economic efficiency and quality of care. Focus is increasingly shifting from individual health care institutions to interorganizational collaboration and health care networks.
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