I can't quite think of an example in my life in which I have acted as the agent of two distinct principals, so I am just going to present a hypothetical situation. In my mind, I see doctors who work for large hospital systems and facing such a dilemma. On one side, they are in fact medical doctors who have sworn to uphold an ethical guiding code for all patients they treat. In this sense doctors are bound as agents of their patients who must uphold the interests of the patient above all outside interests. On the other side, such doctors are also employees of a private organization. As such, they are also agents acting on behalf of the hospital as a whole and must answer to managers and board members. This creates an implicit conflict of interest, since what is best for the hospital in regards to its operations may not necessarily coincide with what is best for individual patients.
So, how can one resolve this issue stemming from the nature of dual principals? I personally do not think there is an easy answer to this, but in order to rectify these conflicting interests I believe that it is crucial to align the interests of the hospital with the interests of the patient. For example, if a radiology doctor knows that his department faces funding cuts if it continues to operate at its current level of profitability, he might be inclined to suggest more extensive and costly procedures for his patients. In order to avoid this dilemma, it is important to separate the mechanisms that govern hospital budgeting from those that affect treatment decisions. It is inevitable that in today's medical environment that doctors must work as part of a hospital or other agglomeration of healthcare services, and seeing as how many such institutions need to operate like a business, it is becoming increasingly difficult to protect the interests of patients. I do not have any first hand experience with healthcare management, however I can see a nearly infinite number of confounding factors such as pharmaceutical interests, insurance concerns, and career advancement. All of these contribute to the gap in the interests between patients and hospitals, forcing doctors to make difficult ethical decisions. Arguably, if it were possible to ensure that doctors would make the most ethical choice regardless of personal or monetary concerns, this would not be an issue. However, it is inevitable that doctors are presented with many conflicting interests and therefore the current system gives them all the power to weigh one principal against another.
Given the hypothetical you articulated, it would have helped if you had gotten deeper into the possible conflict between patient and hospital. One area that is pretty well known in this regard is for patient who don't have health insurance - rarer now with the Affordable Care Act, but still a possibility. If such a patient goes to the emergency room and is suffering from some sever trauma, the hospital is bound to treat the patient by ethical considerations, irrespective of the financial consequences. From a bottom line point of view, however, the hospital clearly hopes there are not many of those sort of patients.
ReplyDeleteFor patients who have extensive health insurance, it is less clear that there is the conflict you talked about between patient and hospital. But I will say this based on my own experience spending 5 days in Carle Hospital two years ago because of an infection in my shoulder. Doctors are extremely busy and if each of them feels, "I am the boss," then sometimes they don't coordinate as well as they might, to the detriment of the patient. In my case, the issue was the care of my wound once I was discharged from the hospital. In that case I was the principal with two agents (the different doctors). Eventually they agreed on the treatment, but I had to force that by not accepting the recommendation of one doctor. It would have been far better, at least for my emotional disposition, had those two doctors agreed beforehand. This experience was a demonstration of some cracks in the system.
I understand that my exploration of this hypothetical is rather limited. I sort of danced around the issue of uninsured patients in need of urgent care because I am still unfamiliar with the systemic implications of the Affordable Care Act. I would hope that a hospital would provide emergency care to patients in dire need of life saving attention, but doing so for uninsured patients raises a payment issue for the hospital as well as large sums of debt for the patients. This case seems to be at the heart of this kind of issue in that it highlights the opposing interests of hospitals' and doctors' ethical obligation to help people while simultaneously trying to run a profitable operation.
ReplyDeleteDespite being young and still under my parents' insurance, I have seen that doctors are quite busy and tend to believe that they are each their own boss. When I was much younger, I father was hospitalized for several weeks and had to undergo multiple surgeries. During this time, he and my mother had to consult a multitude of doctors specializing in different areas of medicine, which naturally led to a great deal of confusion. This represents a coordination failure on the doctors' parts, and that is especially terrifying to the medically ignorant who have little choice but to rely on the advice of their healthcare providers. In this case, it seems that the problem is lack of communication between the various agents reporting to a common principal. In general, it seems that if a principal were to collaborate more openly with his or her multiple agents then some of these coordination failures could be averted. However, I could see this being much harder to do in practice due to time and cost issues as well as the potential of different agents' interest being necessarily in conflict with each other.