Running head: ETHICAL CASE ANALYSIS

7250 Ethical Case Analysis

Cortney Bowen and Lauren Smith
Auburn University/ Auburn University Montgomery

ETHICAL CASE ANALYSIS

2
Abstract

The Patient Protection Affordable Care Act (PPACA) has brought forth the promise of change in
the healthcare delivery system. There is in an increase in aging healthcare consumers, which
may lead to limited supply of providers and resources despite increased demand. This ethical
case analysis will explore the PPACAs impact on healthcare and the possibility of rationing.
Rationing will be summarized and synthesized to present the ethical issues related to this case.
Leadership perspectives will be discussed as it pertains to rationing and the allocation of
healthcare. The economic impact as well as the macro and micro systems application will be
presented in this case to provide a better understanding of the PPACAs change in healthcare and
the possibility of rationing healthcare. This case analysis will provide both positive and negative
impacts of rationing healthcare and various leadership theories to help the reader to understand
more fully the implications for the changing healthcare system.

ETHICAL CASE ANALYSIS

3
Ethical Case Analysis

Healthcare, though every individual needs it throughout their lifetime, is becoming more
limited. People are living longer and requiring more healthcare than before. This rapid growth
in older individuals, known as baby boomers, has increased the demand for healthcare services
even though the supply of healthcare services and providers has not experienced such a vast
growth. The Patient Protection Affordable Care Act (PPACA) has promised changes in the
healthcare delivery system. According to the United States Department of Health and Human
Services the Affordable Care Act puts consumers back in charge of their health care. Under
the law, a new Patients Bill of Rights gives the American people the stability and flexibility
they need to make informed choices about their health (About the Law, 2013). The changes
provided with the act bring the possibility of rationing to the future of healthcare. Ration, as
defined by Merriam-Webster, is to control the amount of something (such as gasoline or food)
that people are allowed to have especially when there is not enough of it (Ration, 2013). In
order for rationing of healthcare to be accepted, it must be seen as fair by the public and not
leave the public fearing that their access to healthcare might be limited. A distinction between
those with non-beneficial consumption of care and above-average consumption by those with
medical need will be important. This ethical case analysis will review the ethical issues
presented with the implementation of this act and the possibility of rationing healthcare. The
importance of leadership during this healthcare change and the differing leadership theories will
be presented. The economic impact as well as the microsystem and macrosystem application
will be discussed. Healthcare change is inevitable and this analysis will provide both sides of the
case in a universal healthcare environment.

ETHICAL CASE ANALYSIS

Summary and Synthesis of the Ethical Case

The case of rationing in a universal health care environment has an extensive list of
ethical issues. Rationing raises many questions and strong feelings from healthcare providers
and consumers. As Americans we have experienced rationing in our past during World War II
with the idea of a little less for some of us, but a fair share for all. This notion may be that fair
is not always equal (Cohen, 2012). The idea of rationing brings up the dispute of all human
beings as equal; yet, more attention or resources should be given to certain people. The citizens
of the United States of America have this persona that everything will be easily accessible if
needed; however, with the Patient Protection Affordable Care Act (PPACA) that belief could be a
thing of the past in relation to healthcare. Although many people accept the necessity of
explicit rationing in theory, they tend to reject rationing when it comes to their own health care or
the care of the people they are concerned about. (Gruenewald, 2012)
Age-Based
Should the younger generation have precedence when it comes to procedures like cardiac
surgery? They could live longer if the procedure was performed early. On the other side, should
citizens over the age of 85 be voided of the chance based merely on age (Klein, 1998)? There
are proposals for age-based rules, which state that individuals above a certain age would not
receive aggressive, costly care at the publics expense (Cohen, 2012). The older generation has
worked and paid to have their healthcare and now are being deemed too old to receive
extensive care; instead they are being prescribed care to keep them comfortable. As healthcare
providers, we cannot assume that a person of a certain age no longer has life goals to achieve.
Another point that is elicited from age-based rationing is that women generally live longer than
men, which means there might be a difference in age cut-off between genders (Gruenwald,

ETHICAL CASE ANALYSIS

2012). There are many negatives that are brought forth, yet there are some positives to agebased rationing. The more extensive and costly lifesaving medical expenses would be used for
the younger generation who deserve a chance to live as long as the older patients. There are
greater outcome possibilities for the extensive procedures in younger patients as well
(Gruenwald, 2012). Ultimately with rationing, it can be seen as providing unnecessary suffering
at the end of life or refusing health care based on statistics.
Decent Minimum
Another proposal is a decent minimum of care that allows individuals to acquire an
education, seek and hold a job, or raise a family. If a person cannot obtain these goals due to
impaired health they will receive a reasonable level of care with comfort, respect, and dignity.
This proposal is dependent of the individuals contributions to society and their community. This
brings discrimination risks for those who face obstacles to education, raising a family, and
employment. The decent minimum would guarantee prenatal care, access to immunizations and
screening, chronic disease management, and life-sustaining intensive care for those patients that
are potentially or actively gaining education, raising a family, or holding a job. This proposal is
beneficial in that it provides preventative care and healthcare for those that fit the criteria. The
problem is that there are seldom easy distinctions in the three criteria needed to obtain the care.
Who can say one family deserves healthcare more than the other based on certain life decisions?
There are non-traditional families that raise children that may not be so easily defined for the
standards. Individuals that do not work but still contribute to society and those with disabilities
that limit them from meeting the criteria all present ethical issues with the decent minimum
proposal (Schneiderman, 2011).

ETHICAL CASE ANALYSIS

Decision Maker
Another ethical issue transpired by rationing is who should make the decision. There has
been much controversy over whether the clinicians should have to make this decision at the
bedside, whether it should be mandated by the organization as a whole or whether the
government should be doing the mandating (Klein, 1998). Who will determine the level of
contributions to society or what age the individual should stop acquiring education or holding a
job (Schneiderman, 2011)? Deciders must keep the decision of allocation separate from their
feelings about the patients character or social values (Cohen, 2012). Decision making erupts
many contradictory and intricate ethical issues whether in favor or against rationing. When
deciding who is worthy of the allotted resources, much burden can be present for the decision
maker.
Implications from a Leadership Perspective
Rationing healthcare brings strong beliefs not only on ethical issues, but also in
leadership theories. To be pro-rationing in healthcare from a leadership standpoint means one
should be totally involved in the patients problems and history. To be anti-rationing in
healthcare means that the leadership standpoint does not feel they should be the ultimate decider
in the allocation of limited resources. As healthcare providers we understand that the decision
for allocation requires a leader with understanding of leadership theories that will make the best
decision.
Leadership Theories
The quantum leader should provide innovative leadership which is about creating
conditions, securing resources, and providing rewards for innovative work (Porter-OGrady &
Malloch, 2011). The leader must know what is available and/or necessary for the patient in order

ETHICAL CASE ANALYSIS

to give the care that is deserved. Although the nurse may not feel some of the patients are
deserving under the new Patient Protection Affordable Care Act (PPACA), it is the quantum
leaders job to justify these decision with other team members. A transactional leader should be
the negotiator for the patient. When under the PPACA, if a patient is disqualified for a certain
procedure or surgery, the nurse should be driven to provide possibilities for the patient to make
end of life or coping decisions easier. The transactional leader should justify rationing by his/her
actions and provide incentives for others to follow and comply with the new act (Ruggieri,
2013). Transformational is opposite of transactional. In this style of leadership, the nurse must
justify rationing by providing support on the subject and encouraging the member to perform
tasks in compliance with this act. Also, having a working decision-making model that
incorporates all team members will increase self-worth and accountability when completing
tasks. For example, if there is a patient who is unable to have a procedure due to the restrictions
in the PPACA, a collaborative team decision should be implemented. This will provide better
compliance (Ruggieri, 2013).
An implication from a shared leadership prospective is that a different leader will have to
rise to each specific event or occasion. Active listening is a main focus with shared leadership
and should always be considered when dealing with a given situation (Porter OGrady &
Malloch, 2013). With the PPACA, the nurse should always attentively listen to the patient and
his or her needs in order to give the patient the best possible care. For example, if the patients
main medical problem is respiratory insufficiency, the pulmonologist should take the lead or if
the problem is heart failure, the cardiologist should take the lead. When the leader is established,
that person will be the one in charge of making decisions regarding rationing of care. The
authors of this paper believe servant leadership is one of the most important styles of leadership

ETHICAL CASE ANALYSIS

regarding implications of universal health care. Relationships have always been a central
component of healthcare, yet understanding these relationships have not been a key factor in
determining how patient care is delivered or the outcomes of care (Garber, Madigan, Click, &
Fitzpatrick, 2009). In reference to PPACA, relationships are going to hold the entire structure
together. Imagine a family who has a grandparent denied chemotherapy due to age. That family
needs nurses and clinicians dedicated to giving them proper respite care. Educated personnel are
required in order to give the patient information on the reasons why chemotherapy was not
available. It is essential the patient is reassured that quality of life is better without the
procedures. This allows everyone affected to move on and be prepared for the outcomes.
To adequately cope with universal health care rationing, clinicians need emotional
intelligence. There are five elements needed to successfully have emotional intelligence. These
are self-awareness, self-regulation, motivation, empathy, and social skill (Porter-OGrady &
Malloch, 2011). Universal health care will have effects on emotional stability because a majority
of the time nurses do not have control over rationing. Some clinicians may see not having
control as a benefit; whereas, others may see it as a weakness. Either way, the patients desire
and require nurses who can provide the best care with or without an emotional struggle. Most
importantly, the nurse must be able to justify rationing of care to the patient and family through
social skill and empathy. Again, this will assist in the process of moving forward.
Economic Analysis
The economy could benefit from universal health care rationing in several ways. First, it
would prevent over-usage of healthcare services. Economic approaches are needed to minimize
wasteful and inappropriate health care spending. About a third of U.S. medical costs are for
services that do not measurably improve health outcomes or health care quality (Gruenewald,

ETHICAL CASE ANALYSIS

2012). If the health care system could stop excessive services, it could provide better quality
care where it is actually needed. Second, the PPACA has a grandfather provision available to the
public. This allows citizens to keep their current healthcare policy if so desired. One of the
advantages of this system will be the requirement of all non-grandfathered plans to meet the
minimum benefit standards as defined by the government (OConnor, 2011). Another benefit is
that the services provided under the private insurance will not affect the services to be rationed
under the universal health care. Lastly, the lower income citizens will pay the same amount of
money for better quality and more inclusive healthcare because of rationing. A procedure that
was desperately needed but never affordable can be obtained through this new system for people
that are qualified. A primary motivation behind this regulation is to ensure that premiums
overwhelmingly reflect costs associated with enrollees receipt of clinical services, rather than
excess profitability or administrative costs that proved little direct value to consumers
(Abraham & Karaca-Mandic, 2011). The proposal of rationing was created to help
economically; however, some disadvantages may be presented with rationing. The rationing will
trickle into the healthcares immense generation of jobs. At a time of high unemployment,
rationing can cut down on the available jobs that healthcare has to offer (Cohen, 2012). The
implementation of the act and rationing will most certainly impact the economy, potentially both
positively and negatively.
Application to Macro and Micro Systems
Rationing can have positive effects to our economys micro and macro systems. The
vast machinery of modern medicine, which can be heroically invoked to save a premature baby,
when visited upon an equally vulnerable and failing great-grandmother, may not save her life so
much as torturously and inhumanely complicate her dying. Dennis McCullough (Gruenewald,

ETHICAL CASE ANALYSIS

10

2012). The numerous unnecessary services provided to one patient whos good quality of life is
unattainable, can be provided to several different patients who can acquire positive outcomes.
This can lead to an overall healthier population. The authors of this paper have both personally
seen a patient go through avoidable stress because the organization or the physician can bring in
some extra money. Say, at present, a cardiac surgeon opens six cases a week. Roughly one out
of six of those cases would be a disqualified case under universal health care. Most likely, that
one case would not have positive results after the surgery whether that is due to noncompliance
or other health problems. Through rationing, that family will not have to go through the costly
and time consuming surgery, which ends up with bad results regardless. Also, the physician can
concentrate on the fewer cases that are eligible, which in turn produces more positive effects.
This provides the organization with fewer re-admissions from the bad cases in which they do
not get refunded financially, ultimately resulting in greater revenue for the organization. This
consequently lets the institution provide better care to the patients at hand and finally results in a
healthier community. The healthier community and more efficient organization provide a better
microsystem which in turn will provide a better macrosystem. The more unified our healthcare
delivery is the more level our peoples health will be and the more chance for the opportunity to
provide more competent ways to maintain and provide healthcare.
Conclusion
The importance of rationing with universal healthcare can be seen as positive or negative
for the nation. It can be expressed in several ways, with benefits and disadvantages affecting
everyone. Increase in the need for healthcare is by far overwhelming the clinical manpower;
therefore, the Patient Protection Affordable Care Act (PPACA) is the governments way of
solving this perceived problem. Although it is portrayed as a way for Americans to have control

ETHICAL CASE ANALYSIS

11

over their own healthcare, the citizens that do not meet standards provided with this new law will
have absolutely no control on whether they receive treatment or not. On the other side, citizens
who desperately need a medical procedure but could not afford it will be able to receive these
services. The authors of this analysis hope the information provided within this ethical case will
provide some direction and information on the implications of the PPACA. Whether a person is
pro or anti-rationing, the initiation of this act is approaching rapidly and one must be able to cope
with the changes.

ETHICAL CASE ANALYSIS

12
References

About the Law. (2013). U.S. Department of Health & Human Services. Retrieved from:
http://www.hhs.gov/healthcare/rights/index.html
Abraham, J. M., & Karaca-Mandic, P. (2011). Regulating the Medical Loss Ratio: Implications
for the Individual Market. American Journal Of Managed Care, 17(3), 211-24. Retrieved
from http:// ehis.ebscohost.com.spot.lib.auburn.edu/ehost/pdfviewer/pdfviewer?vid=10&
sid=faeca737-a709-42b6-8d16-f2f107045900%40sessionmgr114&hid=5
Cohen, A. (2012). The debate over health care rationing: Dj vu all over again?. Inquiry: A
Journal Of Medical Care Organization, Provision And Financing, 49(2), 90-100.
Retrieved from: Retrieved from:
http://ehis.ebscohost.com.spot.lib.auburn.edu/ehost/detail
Garber, J., Madigan, E. A., Click, E. R., & Fitzpatrick, J. J. (2009). Attitudes towards
collaboration and servant leadership among nurses, physicians and residents. Journal Of
Interprofessional Care, 23(4), 331-340. doi:10.1080/13561820902886253
Gruenewald, D. A. (2012). Can Health Care Rationing Ever Be Rational?. Journal Of Law,
Medicine & Ethics, 40(1), 17-25. doi:10.1111/j.1748-720X.2012.00641.x
Klein, Rudolf. (1998). Puzzling out priorities: Why we must acknowledge that rationing is a
political process. British Medical Journal, 317(7164): 959-960. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1114037/
O'Connor, J. T. (2011). Patient protection and affordable care act: Implications of status as a
grandfathered plan. Benefits Quarterly, 27(1), 12-17. Retrieved from http://ehis
.ebscohost.com.spot.lib.auburn.edu/ehost/detail

ETHICAL CASE ANALYSIS

13

Porter-O, T., & Malloch, K. (2010). Quantum leadership advancing innovation, transforming
health care. (3rd ed.). Sudbury, MA: Jones and Bartlette Learning.
Ration. (2013). In Merriam-Webster, An Encyclopedia Britannica Company online. Retrieved
from: http://www.merriam-webster.com/concise/ration
Ruggier, S., & Abbate, C. (2013) Leadership style, self-sacrifice, and team identification. Social
Behavior & Personality: An International Journal, 41(7), 1171-1178.
doi:10.2224/sbp.2013.41.7.1171
Schneiderman, L. (2011). Rationing just medical care. The American Journal Of Bioethics:
AJOB, 11(7), 7-14. doi:10.1080/15265161.2011.577511