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PubMed2005

Financial incentives, cross-purposes, and moral motivation in health care provision.

Financial incentives and disincentives are fundamental to a category of proposals, usually characterised as forms of managed care, whereby the pecuniary interests of health care providers are directly affected by their clinical decision-making. Presently, Australian health care administrators and private insurers are adopting financial incentives as a means of ensuring provider compliance with 'health outcome' and cost-constraint objectives. To the extent that this has occurred, health-care relationships are transformed to emulate, more closely, a commercial transaction. This paper questions the ideological assumptions which inform the use of financial incentives in the health care domain and raises concerns with regard to the potential for financial incentives to undermine the moral integrity of clinical decision-making. It also challenges the legitimacy of rationing health care resources through the use of this measure, particularly when adopted by private insurers of health care.

Australia↗
PubMed2001

Retrospective clinical investigation of the impact of early treatment of children with Down's syndrome according to Castillo-Morales.

BACKGROUND: Infants and toddlers with Down's syndrome are treated at the Department of Orthodontics, University of Frankfurt/Main only when the tongue protrudes over the lower lip, hindering mouth closure. No plate therapy is applied in patients with less tongue protrusion. This study aimed to assess objectively the treatment effects of stimulation plate therapy after Castillo-Morales at this early stage of development. PATIENTS AND METHOD: The follow-up covered 33 children, 20 of whom showed no mouth closure with the tongue resting protrusively on the lower lip at first examination at the age of 8 months. These 20 children received orthodontic treatment based on a stimulation plate. The parents were advised to insert the plate four times a day for about half an hour respectively. The overall treatment time was ca. 2 years. The second group (13 children) received no early treatment, as the functional parameters were only slightly altered at the age of 7 months. At follow-up, the children of the treatment group were between 8.8 +/- 2.3, and those of the control group 8.9 +/- 3.0 years old. The children underwent clinical examination; the parents answered a questionnaire. Additionally, study casts and intraoral photographs were taken along with frontal and profile photographs. The factors assessed were various functions, dentition, facial development, and subjective rating of the parents. RESULTS: In contrast to the initial findings, no difference between the two groups was found at follow-up. CONCLUSION: Early treatment using a stimulation plate thus appears to mitigate or even normalize the initially more severe dysfunctions recorded in the study group as compared to the controls.

Age Factors↗
PubMed2004

Reproductive ectogenesis: the third era of human reproduction and some moral consequences.

In a well known story Derek Parfit describes a disconnection between two entities that normally (in real life) travel together through space and time, namely your personal identity consisting of both mind and body. Realising the possibility of separation, even if it might never happen in real life, new questions arise that cast doubt on old solutions. In human reproduction, in real life, at present the fetus spends approximately nine months inside the pregnant woman. But, we might envisage other possibilities. Historically, the first era is the normal conception inside the woman, the growth of the fetus in the womb and then, after nine months, birth and the appearance of a new individual. The second era is In Vitro Fertilisation (IVF). The fetus starts outside the woman as a fertilised egg, moves to the body of the woman and spends nine month there, where the body of the woman and the fetus travel together in space-time to separate at birth. In the third era of reproductive ectogenesis, the two never travel together. The fetus spends its gestational time entirely outside the woman's body. We have two entities separated in space-time the whole time. The intimate connection consisting in the fetus being a part of the woman's body is gone. In this paper I will briefly comment on the three eras of human reproduction--and primarily on the relationship between the new individual and the woman--and then spend some time with a fictional story illustrating some moral consequences of the third era. The story is from Pig Pharmaceuticals Limited and how they in the year 2050 report the successful development of pig-related pregnancies with transgenic pigs as surrogate mothers.

Animals↗
PubMed1990

Benign moral hazard and the cost-effectiveness analysis of insurance coverage.

When a medical intervention is found to be cost effective, what level of insurance coverage should apply to it? The optimal level of coverage may be less than or greater than full coverage of medical care costs; a finding of cost effectiveness for a service does not necessarily imply v full coverage or coverage at the same rate as other services. If there is some imperfection in the ability to translate higher insurance benefits into higher insurer revenues, the optimal level of coverage will be greater the higher the degree of moral hazard applying to the service.

Aged↗
PubMed1996

Hospital response to prospective payment: moral hazard, selection, and practice-style effects.

In response to a change in reimbursement incentives, hospitals may change the intensity of services provided to a given set of patients, change the type (or severity) of patients they see, or change their market share. Each of these three responses, which we define as a moral hazard effect, a selection effect, and a practice-style effect, can influence average resource use in a population. We develop and implement a methodology for disentangling these effects using a panel data set of Medicaid psychiatric discharges in New Hampshire. We also find evidence for the form of quality competition hypothesized by Dranove (1987).

Adolescent↗
PubMed2006

Reconsidering the moral hazard-risk avoidance tradeoff.

The received model for optimal demand-side cost sharing trades off moral hazard and risk avoidance. This model appears to lie behind recent increases in initial cost sharing, such as those embodied in Health Savings Accounts and Health Reimbursement Accounts. At the same time there is evidence that lower cost sharing for certain drugs can reduce future total health care costs and/or improve future health, and this may be true of other medical services as well. To the degree that individuals remain in the same common insurance pool, lower cost sharing that induces increases in certain services that reduce total costs, including future costs, represents a classic case for a subsidy and will minimize an employer's labor costs. Even if total costs increase, the value of a change in health could increase more. In that case such a subsidy is consistent with recent work in behavioral economics for those with self-control problems.

Cost Sharing↗
PubMed2002

The moral tollbooth: a method that makes use of the patent system to address ethical concerns in biotechnology.

Patents granted for biotechnological innovations continue to cause social and ethical dilemmas. For example, much controversy surrounds the patenting of genes that predispose to breast-cancer, and in the USA the debate continues about whether or not stem-cell technology should be accessible to all. In this report, we argue that some of these concerns can be addressed within national patent systems. In particular, we examine the "order public or morality" clause that exists in most national patent procedures. Furthermore, we propose that patents for inventions that present social and ethical questions should be subject to suspension by an independent, transparent, and responsible tribunal made up of specialists in ethics, research, and economics. This suspension should be reversible so that, when the social or ethical concerns have been addressed in an appropriate manner, the suspension can be lifted. Although controversial, such a flexible mechanism would assist governments and industry in enhancing public support for patents in the biotechnology area.

Animals↗
PubMed1996

Health insurance: the tradeoff between risk pooling and moral hazard.

Choosing optimal health insurance coverage involves a trade-off between the gain from risk reduction and the deadweight loss from moral hazard. This paper examines this trade-off empirically by estimating both the demand for health insurance and the demand for health services. It relies on data from a randomized controlled trial of cost-sharing's effects on the use of health services and on the health status for a general, non-elderly population.

Actuarial Analysis↗
PubMed1997

Altruism or moral hazard: the impact of hospital uncompensated care pools.

Empirical evidence from New Jersey supports theories of hospitals altruism. From 1987 to 1992, New Jersey reimbursed hospitals for uncompensated care through the Uncompensated Care Trust Fund. The Trust Fund reduced the shadow price of charity care, inducing hospitals to increase their provision of uncompensated care. Hospitals increased inpatient uncompensated care by an average of 14.8% and statewide uncompensated care increased by $360 million during 1987-1990. Empirical evidence suggests that the state effectively addressed the moral hazard problem created by the Trust Fund by auditing uncompensated care and regulating hospital collection procedures.

Altruism↗
PubMed1999

The economics of moral hazard revisited.

Pauly's (1968) [Pauly, M., 1968. The economics of moral hazard, Comment, American Economic Review 58, 531-537.] analysis of the welfare loss from insurance assumes that medical care consumption is not determined by income, but recent studies suggest it is. This study argues that (1) Pauly's analysis overstates the welfare loss because it includes the effect of income on consumption, (2) the relevant income effect is derived from income transfer from the healthy to the ill that occur when the probability of illness is less than 1, and (3) the welfare loss can be considered the transaction cost of insurance.

Health Expenditures↗
PubMed2001

Shortcomings of harm reduction: toward a morally invested drug reform strategy.

After a decade of steady diffusion in the drugs field, the harm reduction movement, posing pragmatic public health solutions based on empirical analysis, is still hindered by dissension and general confusion as to its underlying ideals. Despite having short-term political advantages, its 'value-neutral' style of discourse undercuts deeper moral foundations by attempts to forge the common ground in drug debates. Drawing on key statements in the literature and insights from interviews with leading Canadian drug policy observers, this commentary looks at rhetorical shortcomings that may act to encumber longer term harm reduction adoption and promotion.

Journal Article↗
PubMed1998

What if...? Language, health care, and moral imagination.

Language is important to human life. It shapes the way we see our world, is the symbolic means by which we express our knowledge of the world and each other, and guides and justifies our actions. In addition to these roles, language conveys what moral ideas and values are significant to a group. These functions are related and not mutually exclusive.

Attitude to Health↗
PubMed2006

Advances in oocyte cryopreservation technology will eventually blur the ethical and moral boundaries between compensated egg sharing and commercialized oocyte donation.

Compensated egg sharing was originally conceived as a patient self-help co-operative scheme to avoid overt 'commodification' of donor oocytes and prevent doctors and medical institutions from acting as 'brokers' of donated human material. As such, egg sharing is an ethically justifiable and much-preferred alternative to commercialized oocyte donation. However, recent advances in oocyte cryopreservation technology are likely to blur the ethical and moral boundaries between compensated egg sharing and commercialized oocyte donation. The banking of cryopreserved oocytes would negate the requirement for donors and recipients in egg sharing to have co-ordinated and synchronized treatment cycles. Instead, fertility doctors and medical institutions can now offer subsidized fertility treatment upfront to any patient willing to donate a portion of her retrieved cohort of oocytes for banking and subsequent donation. Thus, more opportunity is now open for them to act as 'middle-man' to broker the transaction of oocytes between donor and recipient, which would inevitably result in overt 'commodification' of donated human material. Administrative and processing fees will de finitely be billed to prospective recipients, for banking and storage of the cryopreserved oocytes, which would mean that a direct profit can now be made from the transaction of oocytes between donor and recipient.

Cryopreservation↗
PubMedDate not supplied

The moral status of the embryo: the human embryo in the UK Human Fertilisation and Embryology (Research Purposes) Regulation 2001 debate.

The use of the embryo in research into birth defects, infertility and the possible therapeutic value of embryonic stem cells, has given rise to vigorous discussion of the ethical, moral and legal status of the embryo. This paper considers the parliamentary debate that surrounded the passing of legislation in the UK in 2000 governing the use of the embryo in research. Underlying disagreement by members of Parliament as to whether embryo research was permissible, were considerable differences regarding when life was thought to begin--whether at the moment of fertilization of the egg, or whether after 14 days, at the time of the beginnings of cell differentiation, and the point after which the embryo can no longer split to form twins. Those who favoured the latter view argued that, while the conceptus might possess a unique genetic formula, it had only the potential for life before 14 days, the development of human life being a gradual and continuous process. They considered it mistaken to accord the embryo full human rights. Those who adopted an opposed standpoint insisted that life was present and actual from the moment of conception and therefore sacrosanct and inviolable. The notion of the pre-embryo, they maintained, merely serves to disguise the embryo's humanity.

Bioethics↗
PubMed2005

Ethics and moral philosophy in the initiation of IVF, preimplantation diagnosis and stem cells.

Details of the work leading to the introduction of human IVF, animal and human stem cells, and the preimplantation diagnosis of inherited characteristics in blastocysts are outlined briefly in this paper. The progress of these studies is related to ethical issues emerging during these years. The current status of these studies is outlined, together with a brief moral philosophy as practised by the original investigators.

Animals↗
PubMed1984

Welfare for profit: moral, empirical and theoretical perspectives.

Since the 1960s there has been an increasing number of proprietary agencies engaged in the delivery of social services in the United States. This development has generally been greeted with disfavour by welfare state advocates. Various arguments have been put forward against welfare for profit on moral, empirical and theoretical grounds. This paper analyzes these arguments and proposes several basic conditions that would seem to have significant bearing on the choice between profit and nonprofit providers for a given service.

Ethics, Institutional↗
PubMed2001

Commentary: on the transformation of the moral economy of care.

The documentation amassed in these provisional assessments of the changing terms and conditions of psychiatric work amounts to a reconfiguring of the moral economy of care--those root value-laden assumptions about what constitutes proper conduct in a service or treatment context. Such a transformation appears to have been in the works for some time, but the acuity with which it afflicts the consciousness of present-day actors suggests that a threshold has been crossed. The loss of "slippage" in everyday clinical work, limited recourse of those who would resist the trend, deep "persuasive" impact on non-believers of being forced to "go through the motions," all argue that the ethos of psychiatric work has been thoroughly infiltrated by efficiency, with costs yet to be reckoned. Anthropology may have been slow to take cognizance of such trends, but its improvisational methods and flexible tools should be of use in mapping such costs, direct and indirect, and any countervailing benefits.

Attitude of Health Personnel↗