Nontherapeutic quality improvement: The conflict of organizational ethics and societal rule of law

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Abstract
Critical care ethics focuses largely on patient autonomy. Cost containment is necessary but requires rationing and limitations on a patient's right to consume beneficial services. No laws address a process of autonomy rights limitation to consume resources in the intensive care unit. We analyzed the frictional interface between necessary cost containment as a quality improvement activity contrasted with individual autonomy in the context of the evolution of research ethics. Scholarly books, peer-reviewed articles, congressional record, legal sources, the World Wide Web, and the National Archives and Records Administration were evaluated in the context of current cost-containment-driven nontherapeutic quality improvement activities. Three generations in the evolution of human research ethics are identified: 1) Hippocrates to Nuremberg Code, 2) Nuremberg to Belmont, and 3) Belmont to present. Similar ethical lapses, which place the individual at risk without disclosure for the good of future patients, have arisen recurrently in the course of history and continue presently when nontherapeutic quality improvement activities are framed as a human research activity with essentially no ethical oversight. Consequently, fiduciary obligations of professionals and their employer-institutions to their mutual patients may be at odds, creating complex layers of conflicted decision making. Nonetheless, professional Hippocratic duty to "the patient" must be congruent with the organizational ethos of limited funding "stewardship" to produce meaningful patient care. Medicine's integrity is legally protected and mandated under the state interests (parens patria doctrine) of the common law. When hospitals (society and its health insurance methods) fail to ration transparently under "cost-containment ethics," they threaten the ethical integrity of the medical profession.