Fundamentals of Health Care Ethics
introduces fundamental healthcare ethics, primarily bioethics, including ethical reasoning frameworks of autonomy, beneficence, nonmaleficence, justice, equity, resource allocation, and negligence. (1 credit hour)
After completing the course, participants will be able to:
- Indicate the need for increased ethics in healthcare
- Present social, organizational and patient ethical problems in healthcare
- Demonstrate knowledge of morals, ethics and law within healthcare
- Demonstrate ethical reasoning frameworks of autonomy, beneficence, nonmaleficence, justice, equity, resource allocation, and negligence
Please Review the Following Material:
Why More Ethics Is Needed in Healthcare: Current Healthcare Outcomes
Although clinical ethical perspectives (that is, the views of the dentist working at chair side with patients), are important, they are not the only perspectives that can be used for educating future dentists as well as all professionals within healthcare, and for continually improving overall health operations. A significant reason for increasing ethics education in healthcare, then, is to improve the decision making needed to address the ethical concerns created by the growing use of high technology and the very complexity of our healthcare system (or non-system if we wish to be cynical). The variation of individuals, who have different perspectives on using new technology, and addressing the complexity of its use for each patient’s care, is wide. For example, several health services administrators, in significantly large integrated service organizations, have indicated that some technology available may not be needed, even if it were easily available and brings in substantial revenue. In other words, excellent cognitive or reasoning education for health care providers is provided, but sometimes, other cognitive notions, as well as the affective or feeling aspects of education that also help instill values on the use or non-use of healthcare interventions, are ignored or de-emphasized. Also, health educators may provide the cognitive and affective dimensions of ethics education, but only (or predominantly) within the clinical domain.
The following proposes several reasons why ethics education needs to increase in healthcare. These reasons involve academic gaps in education as well as other holes that are evident through social, organizational, and patient level outcomes.
Social, Organizational and Patient Ethical Problems in Healthcare
Ethics issues in healthcare have existed since the inception of medicine. However, in the United States, several social demarcations have created the need for public discussion of ethical issues. Although not the first demarcation, the creation of Medicare and Medicaid has led to many controversial funds that pay for public mandated healthcare. One of those issues is the right to have an abortion as allowed by Roe v. Wade in 1973. Another issue involves the Health Maintenance Organization (HMO) Act of 1973 that required specific services, but did not include others. Thus a resource issue, or rationing problem, was actually created through the HMO Act. Another is the agreement with the Federal Trade Commission involving matters of money and advertising which limited what could be said about these matters within professional ethics codes and undermined some of the core characteristics needed to develop and nurture professions as a source of knowledge and skill that is separate from and coherent with the economic and political voices of society.
According to Kuhse and Singer (1998), a significant increase of ethical problems in healthcare began in the 1960s up to the 1990s, and that trend continues today. Through the 1980s and into the 1990s and 2000s, many federal level commissions were created to help solve clinical ethics issues. Those first ethics commissions were predominantly focused on clinical judgment and mistakes (Perry, 2002), and did not focus on other ethics domains that are factors in healthcare outcomes. Other ethical issues, for example, evolved as healthcare technology increased, professional authority (in relation to economic and political authority) decreased, and clinical reimbursement rose significantly (Frederickson, 1993). Euthanasia, elective enhancement procedures, and the creation and marketing of non-evidenced based diseases are only a sample of the topics related to these issues.
Another situation that has contributed to healthcare ethical problems is the value free nature of science in general. As Peck (1983) indicates:
in the late seventeenth century…science and religion worked out an unwritten social contract of non-relationship…religion agreed that the ‘natural world’ was the sole province of scientists. And science agreed, in turn, to keep its nose out of the spiritual. (p. 40)
However, as healthcare sciences, and medical and dental science in particular, have grown to include intervention areas once considered to be more religion based and/or social issues (e.g., abortion, cloning, birth control, whitening for aesthetics) the dichotomy of religion and science has diminished and become more intertwined. A more specific form of ethics education, then, is needed to distinguish the religious frameworks and consequences from those of the science based frameworks. Individuals who present themselves as patients have significant variations in their religious perspectives and those perspectives may conflict with pure science based healthcare.
Corruption is also an important part of the ethics outcomes described above. Corruption, here, is used as a very broad term and occurs regardless of any science or religious-based ethics education that is developed and offered in schools and higher education. The amount of corruption in society may be increasing (in relation to the amount of virtue that may also be growing), or at least the type of corruption that is ethically based. Heidenheimer (1970), for example, attempts to show this by presenting three types of corruption:
black, white or grey [with] black corruption involv[ing] actions that are judged by both the public and public officials as particularly abhorrent and therefore requiring punishment. White corruption might be political acts [or administrative acts] deemed corrupt by boththe public and officials, but not severe enough to warrant sanction. Grey corruption involves those actions found to be corrupt by either one of the groups but not both. (p. 14)
Using Heidenheimer’s framework, more white and grey corruption may be now occurring in healthcare than there was thirty years ago or, perhaps, anytime before.
A significant social problem in the United States involves the term access to healthcare. Over 42 to 43 million individuals are without health insurance, but that focuses the problem as one of insurance rather than health care. Still, this does raise additional resource issues about rationing, for example, increased healthcare costs at the highest level, and increased emergency room rather thanclinic visits for non-emergency situations.
Ethical issues are also evident in healthcare organizations. Commonly known examples include ethically inappropriate accounting practices, such as HealthSouth (Bassing, 2003), and previous incidents of alleged fraud, such as HCA/Columbia (Kirchhiemer & Taylor, 2000). Reasons for these organizational level healthcare ethical problems involve the abuse of power usually with a misplaced focus on profit and utility. Hoffman (2001) helps the reader understand how inappropriate power can dominate healthcare decisions:
abuse of power is at least as evident, if not more so, in healthcare organizations as it is in other types of organizations. Examples include rudeness, profane languages, promise breaking, deception, dishonesty, arrogance, use of overly confusing jargon, and withholding information. (pp. 21-22)
The abuse of power is not only demonstrated in the unethical behavior of providers of healthcare but also from those who hold the final authority, the administrators and board members.
Another outcome from the abuse of power is a loss of trust from patients towards care-providers, and care-providers towards those who are in charge. For example, Caplan (1997) indicates that there are several instances of “distrust” in hospitals and other healthcare organizations. The distrust spills over into care and improper services that lead to sentinel health events. According to Brooks et al. (1990) a sentinel health event is an occurrence where “a bona fide quality of care breach [has occurred and could] . . . bring harm to a patient” (p. 184). According to an Institute of Medicine (IOM) report, the amount of sentinel health events is significantly higher than previously thought, including medication errors and improper diagnostics and therapeutic interventions. Although the IOM report was mainly at the patient level, organizational factors that can be alleviated with increased ethics education could help reduce those problems. The most significant interventions, though, as evident in the Scandinavian countries, may be found in the restructuring of medical liability insurance to fit no blame models so as to obtain better insight into the nature of sentinel health events. Such models, though, require an increase of applied ethics education to gain their efficiency and increased health benefits.
Healthcare organizations are only representatives of the individuals who work in them. The structure of the organization may contribute to the outcome of care (Griffith, 2001), but it is the process of care that is at the very essence of healthcare. How well the process of care is provided is based on both the science and art of healthcare. There will never be a situation where healthcare is 100% sentinel event free, but the ethics education in healthcare and in operations could help reduce the problems found at the patient level.
Another ethical issue is the provision of care when not indicated. For example, unnecessary surgical operations fall under the ethical principle of nonmaleficence, the ethical virtue of prudence, and the ethical pragmatics of waste. Individual healthcare providers, since all are human, will make mistakes; healthcare, additionally, is still, more art than science. And unfortunately, some interventions carry significantly more risk (e.g., liver biopsies). Fremgen (2002) makes a poignant case about the nature of healthcare to help frame why ethical issues exist; “there is ample proof in medical malpractice cases that in times of stress and crisis, people do not always make the correct ethical decisions” (p. 2).
These examples of ethical concerns in healthcare indicate at least three levels of issues (e.g., Social, Organizational and Patient). Caplan (1997) presents this issue by focusing on kindness which does not, but ideally should, always and naturally pervade in healthcare:
our society has grown so enamored of personal freedom and self-determination that any act of charity, kindness or beneficence seems extraordinary. Would it not be better if society treated each individual with charity and beneficence as a daily occurrence rather than as an exception. (p. x)
Defining Morals, Ethics, Laws, and Ethics Reasoning Frameworks
Basic ethics issues are discussed to help the reader better understand the context of ethics in healthcare. In this module, the terms moral and ethical will be distinguished to help aid this presentation. Morals will be presented first and then used to help frame the term ethics, and, finally the term law.
Some literature indicates three levels of morals: 1) a social (and/or religious) context, 2) an Individual level context and 3) an interactive social and individual relationship context. Below is literature that supports this particular definition of morals.
According to Corey, Corey and Callanan (1993), morality is based on culture (e.g., social dogma) or religion. Bowie (1997) indicates that the social component of morality is a “set of standards [that is] acknowledged by the members of a culture” (p. 1). These particular authors present morality as a coming together of ideas and standards that individuals simply agree to be correct.
Boatright (1997) presents morality at the social level as standards of “conduct.” Solomon (1996) further suggests that those rules are “inviolable” and point to a specific type of conduct. Flight (1988) and McCollough (1991) are more specific in their discussion when they suggest that morals are based on “right conduct.” With Flight and McCollough there is a condition of morals that indicates a normative position, namely that social morals are positive and point to a specific pattern of ideas and action.
At the social level, Seth (1899), who wrote over 110 years ago, wants us to believe that “moral beings” must learn to be self-controlled, or in essence, act in a way that is socially acceptable. He indicates that without the self-control, society will either “control without” or only from a social context. Seth also points out that morality is based on social “reason” and logically society comes to specific actions that are accepted and not-accepted. This type of moral reasoning closely resembles ethics, but it is without the formal theoretical and scholastic component. In the last century a more theoretical framework has, however, been added to, or perhaps has infiltrated into this sense of simply-accepted-because-society-says-so morality through the addition of non-religious forms of ethics reasoning (which will be introduced below) (McCollough, 1991; Solomon, 1996). That is, there are forms of morality that are based on a faith in reason alone; the role of a religious revelation or a social agreement based morality is thus claimed to be unnecessary. Rather than “I believe to reason” or “I reason to believe” these forms of moral communities are based on the notion that “I reason” is the ultimate community belief. There is growing anthropological evidence, though, that these forms of moral communities are not new and, as suggested within some philosophies of science, are not easily sustained (Girard, 1977, 1986) and (Kuhn, 2009).
At the level of individuals interacting with society, several authors suggest a normative position. Purtillo (1999) wants individuals to have a “morality” whereby their relations between people are “in peace and harmony;” or in other words in a way that is socially acceptable for all individuals. Catalano (1995) indicates that the way to learn morals that are right is through the “socialization” that one experiences in life, hopefully in an environment or social context that positively impacts that individual to be “right.”
Baier (1958) suggests that morals are accepted from society quite simply because moral reasoning is “superior” to all other reasons. With Baier there is an assumption that morals are positive aspects of living that individuals should live by. The positive aspects are actions that are socially acceptable such as paying our taxes, making morally acceptable decisions, and living without committing crime. Rachels (1999) further specifies moral actions as those that are changed or “revised” based on the interests of others. Rachels also offers evidence about how morals can evolve into ethics (within the definition below) through changing contexts, situations, experiences,or different points of view, and even with gaining knowledge about different theoretical perspectives of ethics.
At the individual level of morality, authors are more specific as to how morals give us direction for living. Madsen and Sharitz (1992) indicate that morality is “appropriateness” and Shaw and Barry (1998) suggest that morality is proper “human conduct.” Ferrel and Fraedrich (1997) point to a specific normative position when they say that morals mean what is “right and wrong.” Flynn (2000) also indicates that morals are right and wrong, and also that they involve what is “good and bad, should and should not, and ought and ought not” (p. 3).
The literature above provides a basis for a definition of morals: A set of ideas and actions that individuals believe are correct for living in their respective society. That is, there are specific ways one should act, behave, and be within their definition of society.
Below, based on this definition of morals (that allows every individual to be his own moral expert), is a proposed framework and definition for ethics.
McCollough (1991), Solomon (1996) and Dewey and Tufts (1908) indicate that ethics were derived from the Greek work “ethos” meaning habit, custom or character. (Morales, additionally, is Latin meaning the same—habit, custom or character.) As the English word ethics developed, it became to mean both a set of rules (custom) as well as the aggregate ideas of a group (character assimilation). Seth (1899) suggests that the word ethics is also based on the Greek word “good” relative to customs and character of life.
Ethics is partly about what one ought to do, what is right, or what is the right conduct within some form of theoretical framework (Catalano, 1995; Corey, Corey & Callanan, 1993; Dewey & Tufts, 1908; Durant, 1962; Ferrel & Fraedrich, 1997; Garret, Baillie and Garret, 2001; Harris, 1999; Hoffman & Moore, 1990; Paul & Elder, 2003; Pfeiffer & Forsberg, 1999; Shaw & Barry, 1998; Singer, 1994; Spencer, 1895). Additional authors indicate that ethics is also about knowing why society makes the decisions, hopefully the “correct” decisions, for a “good life” (Beauchamp & Bowie, 1997; Edge & Groves, 1999; MacKinnon, 1998) and “justification” for that life (Solomon, 1996). This group of authors stress that ethics is a means of helping with the ends of decisions.
Another perspective of ethics is pragmatic, or applied, where it is used to resolve, or attempt to resolve conflict. As Hinderer and Hinderer (2001) indicate, ethics is “the study and practice of reasonably resolving situations [where] values or interests appear to conflict” (p. 7).
Paine (1997) suggests that ethics helps enhance “human interactions,” hopefully without conflict. Benjamin and Curtis (1981) believe ethics should help resolve questions and Thompson and Thompson (1981) believe ethics should help with problem solving.
Using the above literature as a framework, then, we can propose a definition for ethics as:
An aggregate of morals within a specific group used to solve conflicts, with reasons why a solution is chosen. Ethics, then, is the ideal, while civil law (which is distinct from definitions of natural law), as discussed below, can offer only a set of standards that are a minimum.
Ethics are based in philosophy and theology and presented as propositions, while civil laws (in contrast to definitions of natural law, and which will not be discussed here), are both codified (Paul & Elder, 2003) and have civil and criminal consequences enforceable by social coercive power. Ethics and laws do overlap, and the nature of that relationship is easily exposed when the spirit of the law is in question. As O’Donnell (1960) indicates, laws are based in “epikeia” or equity; whereby ethics is concerned with the spirit of the law. A person may not be in violation of the law due to the strict interpretation, but that person may be in violation of an ethical framework that helped form and articulate the law, thus the spirit of the law.
Beauchamp and Bowie (1997) explain further about ethics and the law when they indicate “law is the public’s agency for translating morality into social guidelines and practices for stipulating punishments for offenses” (p. 4). An individual may be punished for offenses of the law, but they are rarely punished for offenses against an ethical framework (e.g., an ethical code). However, though some claim there may be more ethically appropriate behavior if there were punishments for “unethical” actions, introducing coercion into ethics undermines one of the key characteristics and the sustaining power of ethics as propositions that can be explored in dialogue and creativity.
When civil law is broken, individuals may be held accountable for their offense by some “authority” (Darr, 1997). Garrett, Baillie and Garrett (2001) indicate that the punishment is about how that offender affected the “public good.” In healthcare, the individuals most significant at risk of offending the public good are (or perhaps were) providers of care. As Flight (1988) indicates, physicians risk for harming the public good are multiplied due to their professional authority and the “vicarious liability” or behavior of their employees and others who carry out their orders. Even if physicians do not directly employ other healthcare providers, they are typically in charge of a patient and, by indirect means, are still responsible for the ultimate care, and all the other care-providers of that care, to the patient. Dentists are also in a vicarious liability situation as they provide the totality of care for patient’s teeth and oral structures, and all the other support need to offer that care (e.g., hygiene, use of anesthetics, and distribution of medications).
Other providers who have ultimate responsibility for care include chiropractors, nurses in some instances, especially nurse practitioners, physical and occupational therapists, and health services administrators who are licensed (i.e., nursing home administrators). Health services administrators who are not licensed are also at risk for ultimate responsibility of care if they are found to be negligent of keeping the health organization structured appropriately for the care that is provided.
Flight (1988) provides a list of legal issues in healthcare that include:
abuse, fraud, search and seizure, rape, assault and battery, invasion of privacy, defamation of character, false imprisonment, intentional infliction of emotional distress, and negligence. (pp. 28-39)
There are a significant number of other legal issues in healthcare, but these above are especially obvious for direct care providers.
A proposed definition for law, then, is:
A set of codified civil rules that may change, that limits actions (usually through negative rights or prohibitions defined at a minimum level), and that have the coercive power to enforce the repercussions of going beyond those limits.
Ethics Reasoning Frameworks
The seven ethics reasoning frameworks that will be discussed here are the principles of autonomy, beneficence, nonmaleficence, and justice, as well as two specific forms of justice—equity and resource allocation, and a specific variation of non-maleficence—negligence. These seven principles , and how they are understood, applied, and balanced have a significant effect on the outcomes of healthcare, the availability and/or provision of healthcare services, the accessibility and means of obtaining healthcare, and the attainability of payment methods for healthcare. These are not the only forms for framing ethical thinking; there are others such as virtues, moral sensitivity, casuistry, pragmatics and at least 20 others that can be listed in a moral/ethical thinking taxonomy. The first ethical reasoning frameworks presented here, though, are the principles of autonomy, beneficence, nonmaleficence and justice; they are presented as discussed by Corey, Corey and Callanan (1993) as:
[Autonomy is] self determination or the freedom of clients to choose their own direction. Beneficence, refers to promoting good for others. Nonmaleficence means avoiding doing harm, which includes refraining from actions that risk hurting clients. Justice refers to providing equal treatment to all people. (p. 9)
Balancing each of these principles is difficult for clinicians, especially when conflicting ethical,and patient based religious moral frameworks are evident in the planning of care. The major reason underlying the difficulty of balancing these principles is that they are philosophically designed to be in conflict simply because each are independent and unranked prima facia, or first look conceptual tools, to deciding what should or should not be done. Additional conflicts may also exist, however, due to patients, family or friends ideas whether or not they are factually based on adequate evidence, as well as personality conflicts between patients and providers. One means of focusing all of these conflicting components, however, is to have some of the patients’ health care beliefs articulated prior to healthcare interventions through a living will or advance directive; this is especially helpful if there is a history of cognitive and or other decision making capacity deficits known or apparent in a family. Another tool is to have the patient appoint a designated surrogate decision maker who can offer some sense of what a patient may want based on long term familiarity and friendship with a particular patient.
In addition, the particular subset of the justice theme – equity and resource allocation -become paramount issues when dealing with particular healthcare resources that become limited either periodically, or consistently (Herlihy & Golden, 1990). Equity offers a framework whereby patients do not have their healthcare “blocked,” and resource allocation is broadened to include all the means of gaining “equitable” distribution of at least the basic services of care. Several ethical theories help guide the clinician on how to balance these two issues with those directly above (e.g., distributive justice ethics and acceptance ethics (Patthoff & Corsino, 2001). An example of an equity and resource allocation problem that has been discussed and decided on, with a variety of outcomes, is the issue of state level healthcare reimbursement.
The final principle discussed here is one specific form of non-maleficence—negligence. It is important because it is the underlying ethic that shapes current approaches to malpractice law and the structure of liability insurance. As defined by Harris (1999) negligence “[is] duty, breach of duty, causation, and damages” (p. 171). Without all four components, negligence is not in evidence. However, the ethics of negligence, in terms of a perception of negligence versus the evidence of negligence, must be balanced by the clinician. One malpractice case based on a claim of negligence can harm years of goodwill created by the clinician. These four components of negligence should be foundational considerations of all patient care planning.
A great deal of literature is available in law and malpractice that indicate how clinicians can improve their care by keeping the four components of negligence in mind. Until society and healthcare are able to move to a no-blame insurance based system for addressing unplanned outcomes, another perspective to consider is to add more ethics education, that includes the domains discussed here, and that demonstrate their effectiveness and efficiency in helping to alleviate the potential for negligence in healthcare. With time, this education should help address and start to correct the social or systems level of ethical conflicts.
The skill of clinical care includes, then, more than clinical knowledge and skills education; but also the ethics education necessary to effectively, efficiently, and safely use those clinical skills and knowledge. As the ethics perspective of clinical education increases, the amount of malpractice cases could be reduced, but only if the underlying social and systemic ethical issues are better discussed and then adapted into the culture and laws of society.
Partial List of References and Suggested Reading
Accrediting Commission on Education in Health Services Administration. (2003). Accreditation Criteria. Retrieved on November 21, 2003 from www.acehsa.org.
Agich, G. (1996). Human Experimentation and Clinical Consent. In. J. Monagle & J. Thomasma (Eds.). Health care ethics: Critical issues for the 21st century. (p. 230). Gaithersburg, MD: Aspen Publishers, Inc.
Altman, S., Reinhardt, V., & Shields, A. (1998). The future U.S. healthcare system: Who will care for the poor and uninsured? Chicago: Health Administration Press.
Altenburger, J. (1992). Patronage: Ethics gone amok. In P. Madsen & J. Shafritz (Eds.), Essentials of government ethics (p. 353). New York: Penquin Books.
Ashley, B., & O’Rourke, K. (2002). Ethics of health care: An introductory textbook. Washington, DC: Georgetown University Press.
Beauchamp, T., & Bowie, N. (1997). Ethical theory and business 5th Ed. Upper Saddle River, NJ: Prentice Hall.
Boyle, P., DuBose, E., Ellingson, S., Guinn, D., & McCurdy, D. (2001). Organizational ethics in health care. San Francisco: Jossey Bass.
Brannigan, M., & Boss, J. (2001). Healthcare ethics in a diverse society. Mountain View, CA: Mayfield Publishing Company.
Edges, R. & Groves, J. (1999). Ethics of healthcare: A guide for clinical practice. Albany, NY: Delmar Publishers.
Emanuel. E. (1991). The ends of human life: Medical ethics in a liberal polity. Cambridge, MA: Harvard University Press.
Flynn, E. (2000). Issues in healthcare ethics. Upper Saddle River, NJ: Prentice Hall.
Fulford, K., Dickson, D., & Murray, T. (2002). Healthcare ethics and human values: An introductory text with readings and case studies. Malden, MA: Blackwell Publishers.
Garrett, T., Baillie, H., & Garrett, R. (2001). Health care ethics: Principles and problems (4th Ed.). Upper Saddle River, NJ: Prentice Hall.
Harris, D. (1999). Healthcare law and ethics: Issues for the age of managed care. Chicago: Health Administration Press.
Hinderer, D., & Hinderer, S. (2001). A multidisciplinary approach to health care ethics. Mountain View CA: Mayfield Publishing Company.
Hoffman, P., & Nelson, W. (2001). Managing ethically: An executive’s guide. Chicago: Health Administration Press.
Jacobs, P., & Rappoport, J. (2001). The economics of health and medical care. Gaithersburg, MD: Aspen Publishers.
Monagle, J. & Thomasma, D. (1998). Health care ethics: Critical issues for the 21st century. Gaithersburg, MD: Aspen Publishers, Inc.
Nelson, W. (2001). Evaluating Your Ethics Committees. In: P., Hoffman, & W., Nelson (Eds.). Managing ethically: An executive’s guide(p. 208) Chicago: Health Administration Press.
Patthoff, D. & Corsino, B. (2001). Universal patient acceptance: Ethics pipe dream or key to improved access to dentistry? J Am Coll Dent; 68(4):39–43
Perry, F. (2002). The tracks we leave: Ethics in healthcare management. Chicago: Health Administration Press.
Porter, R., & Schick, I. (2003). Revisiting bloom’s taxonomy for ethics and other educational domains. Journal of Health Administration Education, 20, (3). 167-188.
Purtillo., R. (1999). Ethics dimensions in the health professions (3rd Ed.). Philadelphia: W.B. Saunders Company.
Rachels, J. (1999). The elements of moral philosophy (3rd Ed.). Boston: McGraw-Hill.
Ross, A., Wenzel, F., & Mitlyng, J. (2002). Leadership for the future: Core competencies in healthcare. Chicago: AUPHA/HAP.
Schick, I., Porter, R., & Chaiken, M. (2002). Core competencies in ethics. Journal of Health Administration Education. Special Edition, Winter. 149-158 [Author’s Note: First and last author’s names switched at printing for this article. Printed article has Chaiken, M., first and Schick, I., last.]
Seth, J. (1899). A study of ethical principles. New York: Charles Scribner’s Sons.
Shi, L., & Singh, D. (2001). Delivering health care in America: A systems approach. Gaithersburg, MD: Aspen Publishing.
Thomasma, D. (2001). Ethical duties to employees. In P. Hoffmann, & W. Nelson (Eds.), Managing ethically: An executive’s guide (p. 80). Chicago: Health Administration Press.