Confronting change.

AIM: To explore the considerations and influences on decision making of doctors and managers when faced with ethical dilemmas. METHOD: Two hundred and eighty-four doctors and managers responded to a mailed survey. The questionnaire probed the types of considerations that were salient in the ethical dilemmas faced by doctors and by managers, the support these groups received for reflection on these difficult decisions, the specific influences on their decision making and their perception of future ethical issues in the health sector. RESULTS: The study found that doctors and managers report encountering a similar frequency of ethical dilemmas in their work but apply significantly different considerations and influences in their decision making. They reported similar levels of support from their colleagues but differing levels of support from their managers and the Crown Health Enterprise overall. CONCLUSIONS: This study highlights various areas of dissonance between different stakeholders in the public health sector, in particular, between the manager representing the organisation's interest and the doctor representing the patients' interests. Policy makers, purchasers and providers need to consider the infrastructure required to support doctors and managers in their work. Above all, with more ethically challenging decisions ahead, there needs to be clarity over the decision-making role of the government, the health manager and the doctor.

Clinical Medicine↗

PubMed1999

Avoiding the unintended consequences of growth in medical care: how might more be worse?

The United States has experienced dramatic growth in both the technical capabilities and share of resources devoted to medical care. While the benefits of more medical care are widely recognized, the possibility that harm may result from growth has received little attention. Because harm from more medical care is unexpected, findings of harm are discounted or ignored. We suggest that such findings may indicate a more general problem and deserve serious consideration. First, we delineate 2 levels of decision making where more medical care may be introduced: (1) decisions about whether or not to use a discrete diagnostic or therapeutic intervention and (2) decisions about whether to add system capacity, eg, the decision to purchase another scanner or employ another physician. Second, we explore how more medical care at either level may lead to harm. More diagnosis creates the potential for labeling and detection of pseudodisease--disease that would never become apparent to patients during their lifetime without testing. More treatment may lead to tampering, interventions to correct random rather than systematic variation, and lower treatment thresholds, where the risks outweigh the potential benefits. Because there are more diagnoses to treat and more treatments to provide, physicians may be more likely to make mistakes and to be distracted from the issues of greatest concern to their patients. Finally, we turn to the fundamental challenge--reducing the risk of harm from more medical care. We identify 4 ways in which inadequate information and improper reasoning may allow harmful practices to be adopted-a constrained model of disease, excessive extrapolation, a missing level of analysis, and the assumption that more is better.

Clinical Medicine↗