Healthcare Improvement And Healthcare Ethics: Time For The Twain To Meet

Good healthcare is, by definition, of at least some positive value. But there are many things we could consider before judging any particular examples of healthcare to be good, and not all practical efforts to improve healthcare are entirely positive: they can, for example, cause harm, waste resources and treat some people unfairly.

In this article, we outline the need to develop work on the ethics of healthcare improvement, focusing especially on the more formalised quality improvement (QI) approaches. We start by considering the different emphases that QI and healthcare ethics bring to the idea of ‘good’ healthcare. We look particularly at the value that insights from healthcare ethics can add by emphasising that healthcare quality is not fully or simply a measurable property. And, we note a few key questions that an ethics of healthcare improvement could usefully address. We suggest that both the healthcare improvement and healthcare ethics fields might benefit from more cross-field working.

GOOD HEALTHCARE: WHAT QI EMPHASISES

Within the broad field of healthcare improvement, QI is well established as a professional or quasi-professional activity: health service staff, often with designated QI roles, sometimes working with academic and patient/community collaborators, employ a set of QI tools, techniques and methodological standards that have now been refined by decades of research and development. QI projects involve intervening in carefully designed ways to improve specific and measurable aspects of healthcare quality – typically but not exclusively related to healthcare safety, effectiveness and cost-effectiveness.

The technical-methodological commitments of QI mean that the kinds of healthcare ‘good’ it focuses on and pursues are ‘measurable properties’ of healthcare that project teams and sponsors deem to be indicators of (aspects of) quality. Progress towards better healthcare is judged by assessment of the changes in these measurable properties – for example reductions in the number of central line infections among patients in oncology services, increases in the proportion of people with diabetes who have blood pressure and blood glucose levels within target ranges, reductions in the prescription of brand name medicines for a condition for which cheaper generic equivalent medicines are available, or increases in the proportion of service users who indicate on questionnaires that their healthcare team involved them in decisions about their treatment.

QI approaches have several important merits. They reflect values of clarity, transparency and empirical testability. Projects that conform to QI ideals are likely to be taken seriously and gain practical policy support in contexts where a strong emphasis is placed on the kinds of quantitative evidence that they are able to generate. But as we noted in the introduction, QI projects are not necessarily entirely positive. And because some of the problems they can generate will not be evident within their own frames of reference, perspectives associated with the field of healthcare ethics can be useful to illuminate and help address them.

GOOD HEALTHCARE: A BROADER VIEW FROM HEALTHCARE ETHICS

Healthcare ethics is a wide-ranging field of inquiry. A relatively small but diverse group of healthcare professionals and academics engage in it professionally, and many more people from all walks of life engage in it at least occasionally as they consider and critically discuss what is good, right and justified (or not) in healthcare – what should or ought to be done, and why?

Ethical analyses and debates about QI specifically and healthcare improvement more generally can examine many ideas about what might be considered good in healthcare, and they do not normally approach the question of what is good through the lens of measurement. Within healthcare ethics, claims that one form of healthcare is better than another can reflect qualitative evaluative comparisons, and the rigour of these claims can be debated and tested in conversations that include consideration of uncertainty and disagreement about what particular health services are for, about what kinds of good have been achieved and how, and about which features and experiences of healthcare should be prioritised and why.

Relatively little work in healthcare ethics to date has focused explicitly on the ethics of QI or of healthcare improvement more broadly. There have been discussions about the ethical governance of QI (about whether and how QI projects should be regulated in a similar way to health-related research projects) but these have tended to rely on a QI kind of framing and to be rather limited in scope, envisaging a weighing up of the intended and likely improvements in the selected measurable properties of healthcare against any risks of physical or psychological harm that people might need to be protected from. But ethics encompasses much more than this, and is much more than what ethical review boards or ethics committees do when they decide whether or not a highly contested procedure, a research project, or even a QI project should go ahead, especially if their decisions are constrained by particular criteria.

The agenda for an ethics of QI could usefully include questions such as:

• Whose perspectives and which values are built into the design of particular QI interventions, and whose perspectives and which values might have been obscured?
• What assumptions about what matters are reflected (or not) in the ways widely endorsed quality concepts are operationalised into measurable properties of healthcare? How adequately do the measures used to assess an aspect of quality (e.g. safety or effectiveness) capture what different people consider important for that aspect of quality?
• What else that people can reasonably consider important for good healthcare is affected, either positively or negatively, by QI interventions and/or associated measurement activities?
• What challenges do QI activities pose for people working on them and for people whose healthcare work or experiences as patients, family members or communities are, or may be, affected by them?

Some of these questions are perhaps more likely to be raised and attended to in relation to aspects of healthcare quality that are more readily recognised as contested, such as patient- or person-centredness and equity. In the case of patient- or person- centredness there is a growing concern that QI approaches could end up undermining the promotion of intended benefits because neither the kind of interventions that are assessed nor the measures of patient experience used to evaluate them (if they are different) reflect anything like the scope and complexity of what can matter for patient- or person-centredness. However, it is important to remember that all aspects of quality are ethically complex and even established measures of effectiveness have involved value-laden decisions in their development. Ideas about effectiveness that remain possible even if they are rarely considered include notions that treat it as a function of what matters to individual patients. More individualised assessments of effectiveness could perhaps enhance the responsiveness or sensitivity of judgements of good healthcare, but they would also be less practicable for comparisons of services and for overall evaluations of interventions.

This tension leads us to suggest that another key but rather neglected question that an ethics of QI could usefully address is:

• How should we strike a balance in healthcare improvement work between approaches that treat quality as a measurable property and approaches that treat it as an evaluative judgement?

POTENTIAL BENEFITS OF CROSS-FIELD WORKING AND LEARNING

Although QI and healthcare ethics are both concerned with ‘good’ healthcare, the people who work on them typically do so in separate groups. The different emphases within their approaches to good healthcare are likely to pose some challenges to collaborative working, but there is scope for both fields to benefit from closer engagement. The field of healthcare ethics could arguably be expanded and enriched by closer engagement with the practical realities and ethical challenges of QI and healthcare improvement, and there is significant scope for healthcare improvement work to engage more explicitly with its normative assumptions and potential downsides.

This piece is based on work funded by the Wellcome Trust (209811) and published in the Journal of Medical Ethics: Cribb A, Entwistle V, Mitchell M. What does ‘quality’ add? Towards an ethics of healthcare improvement. J Med Ethics, 2020; 46: 118-122.