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Dialogues@RU is published annually
by the
Writing Program at
Rutgers, The State
University of New Jersey
Volume One
Spring 2002
The Routinization
of Health Care and the Professional Calling -
Page 5
by Megan H. Johnson
The presence of the HMO in the health care industry has led to similar situations for doctors, whose moral connections to their work are increasingly challenged. Doctors are faced with ethical dilemmas related to patient care, as Jacqueline Eastman discusses in her article, "The Relationship between Ethical Ideology and Ethical Behavior Intentions: An Exploratory Look at Physicians' Responses to Managed Care Dilemmas." Eastman writes of several ethical issues faced by physicians involved with health maintenance organizations, including the problem of under-treatment:
In the traditional fee-for-service system, a physician who provides more services for a patient receives more income because a fee is charged for each service. Managed care plans may save money not only by squeezing inefficiencies out of the system, but also by refusing needed care (e.g. by limiting needed referrals, nor ordering needed tests, or refusing emergency room claims)...Nearly one third of physicians had to withhold medical services at the request of a health care management organization. (11)
In scenarios like these, doctors are urged by HMOs into pursuing courses of treatment that are financially preferable, despite objections that they may have based on their sense of morality. The doctors' ability to integrate their personal value systems into their work is diminished when they are forced into "limiting needed referrals, not ordering tests or refusing emergency room claims." As a result, physicians end up distancing themselves from the work they do, and are prevented from keeping their work "morally inseparable from their lives" (Bellah 66). As suggested by the estimate that "nearly one third of physicians had to withhold medical service," doctors can no longer simply do what they morally feel is best for their patients; rather, they must prescribe care with the wishes of cost-concerned HMOs in mind, and are sometimes forced to divert from their personal moral code in the name of business.
Efforts to cope with the often negative realities brought about by the onset of HMO intervention and the nursing shortage tend to move the health care professions even further from their roots as "callings." Related to this issue is the third criterion that Robert Bellah uses to qualify work as a calling: the drive of the individual to perfect his or her craft and "[master] a discipline" (67). In some instances, though, the proposed solutions to current problems in the health care industry discourage this ideal. Donald E. L. Johnson makes some suggestions for ways to counter the understaffing of nurses in his article, "Hospitalists May Help Relieve Nurse Shortage," asserting that the solution is to lower standards in the profession, rather than raise them. Johnson believes that while pay increases will help draw some people to the field, more comprehensive changes must be made, and recommends a "re-engineering of the nursing and nursing management professions" (2). His proposals include "rewriting nursing job descriptions to fit the available talent, dumbing down nurse training programs to make them less daunting and expensive, easier to complete and easier to teach...[and] relaxing licensure requirements"(3). The words Johnson uses to illustrate his ideas clearly suggest lowering standards instead of raising them, and any recommendations that urge "dumbing down" and "relaxing" programs so that they are "easier" will certainly not foster an environment of professional excellence, even if they allow for a short-term fix. While these ideas could conceivably put more people in nursing positions, they clearly don't seem to be ideal long-term solutions to the nursing shortage. Johnson observes that "the smart, dedicated young women who used to flock to nursing schools are being warned away by frustrated nurses and attracted by more appealing lifestyles offered by business, the law and medicine," yet his proposed solutions do little to change this reality in a positive manner, and would only mire the profession in deeper problems (3). These "smart, dedicated young women" (and men) would only be driven further from the profession if standards and job prestige drop in the manner that Donald Johnson recommends, and dedicated nurses currently in the field would likely be frustrated by less-qualified new recruits. In light of these probable repercussions, Johnson's requests to "dumb down" and "relax" nursing programs and licensure requirements would do nothing to foster the ideal of "mastery of a discipline" that Robert Bellah encourages (67). The related current practice of using low-skilled auxiliary workers as nurse substitutes or "nurse extenders" has helped the plight of overworked nurses very little, as Marie Cowart notes in Nurses in the Workplace:
At first, nurses welcomed the extra help in the understaffed ICU. Problems soon arose, however, as nurses found themselves spending an increasing amount of time checking the work of technicians. While doing routine tasks, the nurse simultaneously provides other forms of care that cannot be provided by technicians -- such as giving emotional support, teaching, explaining procedures, and making assessments that affect the outcome of care. (21)
Evidently, what the nursing field needs is more bright, compassionate professionals who endeavor to "master their discipline" while lending this "emotional support" as they continue "teaching, explaining procedures and making assessments" - not more haphazardly trained technicians, as Donald Johnson suggests. Some additional positive suggestions for improving the nursing profession, both in numbers and in quality, include making a baccalaureate degree in nursing the minimum preparation for professional nursing, as well as making an associate's degree the minimum preparation for lower-level technical nursing. To facilitate these goals, non-college diploma programs would be closed, and LPN and associate degree programs would be merged, with a focus on doubling the output of B.S.N. programs (Cowart 26). Reforms like these would lead to "mastery of a discipline" by encouraging brighter, more ambitious and more conscientious young men and women to enter into the field. Furthermore, when these stronger recruits would graduate nursing school, these reforms would ensure that they would be better educated and better prepared for the demands of the nursing profession. While Donald Johnson's suggestions for "dumbing down" nursing programs in an effort to make them "easier to complete" would hardly foster an environment in which Bellah's ideal of "mastery of a discipline" could be encouraged, these latter proposals do more to revitalize dedication and pride in the nursing profession, bolstering its historical identity as a calling.