Outpatient Ethics

While traditionally we tend to think of medical ethics in the hospital or hospice setting, there is considerable interest recently in outpatient ethics.  At a recent of conference of the American Society for Bioethics and Humanities, I attended a presentation on addressing ethical issues in the outpatient setting.

This is a new area of research and practice for at least two reasons. First, much of medical practice is moving to outpatient, ambulatory care settings and long-term care that is provided in patients’ homes. This trend has been driven by a number of factors, particularly patient preference. Nobody wants to spend long periods of time in hospitals, and we especially don’t want to have to come back repeatedly, either after a surgery or an illness. It also costs quite a lot to keep hospitals and long-term care facilities up and running, which in turn drives up the cost of care provided in hospitals and other settings.

Further, there is evidence that people do better when they are at home and back in their lives, though there is some dispute about this, particularly for people who need long-term care. Following these trends of patient preference, high costs, and improved outcomes, Medicare and Medicaid have created financial incentives for treatments and care to be provided in outpatient settings or in the home, including penalties for a patient’s unexpected readmission to the hospital shortly after being discharged. 

With this push towards treatments and care in the outpatient setting, we need to focus on some of the ethical issues that these settings raise—issues that perhaps have not been receiving the attention they deserve. Most of the ethics resources at institutions are focused on the inpatient setting in part because the foundational issues in recent bioethics were around technology that was only available in hospitals Also, in inpatient settings, the ethical issues are right in front of the health care professional.  When the patient goes home, the issue may continue, but it may not always be as evident to the provider.

This brings up the second reason for interest in this area: Ethical issues in the outpatient setting can be quite different from those in the inpatient setting. These issues are perhaps not different in nature, but may be different in practice. One of the ethical issues faced in hospitals and inpatient settings is the clash of values about what should be done for patients between providers, between patients and providers, and within families. When patients are at home, there may still be clashes of values, but they may now include family members who are acting as caregivers and having to balance their role as providers with their own needs and values. 

Surprisingly little research exists on this unique context and its corresponding challenges.  The Ethics Center itself hopes to address some of these issues in an upcoming project, and we look forward to seeing the work of others entering this space.