Health, Spirituality and Medical Ethics

 

Introduction

J

ustice is a basic human need (1) that should be fulfilled like other needs (2). Furthermore, justice is one of the most frequent words in every nation (3). Accordingly, healthcare systems around the world are striving to achieve justice in medical care (4). Justice, autonomy, beneficence, and non-maleficence are the four basic principles of healthcare ethics (5). Justice is an index denoting the delivery of rightful, fair, impartial, and equitable care to all patients (6). Besides, justice is more than mere equality; it means that we accept certain responsibilities under certain conditions for the treatment of



patients and act without discrimination based on the patients’ property, position, or race (5).
According to the principle of justice, we must act equally in equal situations and differently in unequal situations (7). Equality in health care is defined in three forms, including equal access to care for equal needs, equal use for equal needs, and equal quality of care for all that demand it (8). According to the Iranian patient’s rights charter, receiving desirable healthcare services is the right of the patient. Accordingly, each patient should be provided with the required services regardless of ethnicity, culture, religion, disease type, or gender (9). Healthcare injustice leads to resistance and conflict in society. Furthermore, those who experience this issue lose their trust in the healthcare system. Injustice itself is regarded as a stressful and detrimental factor for health and welfare that is accompanied by such consequences as shock, harm, anxiety, depression, and hopelessness (1). Access to public goods, including health care, education, and public health, is limited, while there is a tremendous demand for them (10). This underscores the need for rationing to achieve well-being for the whole community (11), and nursing is no exemption. The nursing practice encompasses a variety of tasks, and when the resources are scarce, the nurses are forced to ration their attention to patients and minimize or eliminate specific tasks (12).
Recent studies on nursing care rationing have shown that nurses always ration their time and care, which is a serious threat to health care quality and patient safety (13, 14). Rationing of nursing care involves not only the economy but also ethics since it requires resolving the potential conflicts between individual and professional values. When nurses complete, delay, or eliminate care, they are under the influence of personal factors (e.g., their values, attitudes, and beliefs about their roles and responsibilities), which shape their behavior (15).
Healthcare rationing is a morally complex issue; therefore, transparency in this practice is an important structural consideration in the establishment of a fair and commensurate healthcare system. Moreover, it requires careful selection through rational practical principles and fair methods (10). Rationing of nursing care is affected by various factors, even those that do not adhere to medical ethics. One of these factors is patient favoritism. One type of patient favoritism is to prioritize a patient regardless of any rules and laws only because they are recommended by authorized people or relatives (16). Tayebi et al. (17) used the term “private patient” in their study and stated that all the patients experience difficulties for visiting a doctor, except those who are the family members of the nurses or physicians.
With this background in mind, the present study was conducted as a part of a larger qualitative study addressing justice in healthcare. This study explores one of the sub-concepts discovered in the above-mentioned research, which is “patient favoritism”.
Methods
The present qualitative study was based on some data derived from another qualitative study, titled “Investigating the process of achieving justice in the delivery of nursing care” using content analysis. Patient favoritism which is the focus of the current study was discovered as a sub-category in the mentioned research. The study population of the present study mainly corresponded to a group of nurses.
In the sampling process, it was attempted to select those who were more knowledgeable and experienced regarding the concept of justice in healthcare. First, the convenience sampling method was used for selecting the nurses, and then the rest of the participants were selected purposefully. Furthermore, as the study went on, more participants were included in the study based on the emerging concepts; accordingly, theoretical sampling gradually replaced purposive sampling, which continued until data saturation. In total, 22 participants (i.e., 16 clinical nurses and nurse managers on a macro level and 6 healthcare policymakers) contributed to this study. The data which were extracted from the interviews were analyzed for the second time in order to discover and specify the aspects of patient favoritism through qualitative content analysis.
Data collection was accomplished using semi structured in-depth interviews. These individual interviews were conducted in a quiet environment in the workplace of the participants after making previous arrangements. The interview started with introductory information and inquiries on experiences, and continued with general questions about the subject of the study like “What is just and unjust care?” Each session was guided based on the interviewees’ answers and the data gathered from the interviews. After patient favoritism came up, the interview progressed with questions, such as “Have you experienced patient favoritism?” or “Based on your experience, what are the differences between such patients and the others?”
During the interview, the researcher used some expressions (e.g., “Would you elaborate?” and “What do you mean?”), repeated some of the participants’ words, and paused when it was needed in order to deeply involve the participants. In addition, all of the interviews were recorded with the permission of the participants. Subsequently, the interviews were transcribed verbatim as soon as possible. The interviews lasted 30-80 min and were averagely 45 min long. The required permissions were obtained from the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran, on 2/4/2013 (91D1302870). The study participants were informed about the study objectives and possibility of study withdrawal at any time. In addition, written informed consent was obtained from all subjects regarding their participation in the study and recording the interviews. The anonymity was also maintained through coding the participants.
The gathered data were analyzed through content analysis. All of the interviews of the previous study were digitally recorded and then transcribed verbatim. The transcriptions were reviewed, coded, and analyzed. Moreover, for the purposes of the present study, they were examined once again in order to discover and determine the different aspects of patient favoritism which had emerged as a subcategory of the previous study. Therefore, all of the codes that were related to patient favoritism were separated from the other ones.
Units of meaning were extracted from the interviews as initial codes and then studied several times. Codes that were similar or analogous were grouped into one category. Categorization was conducted by means of coding, repetitive reviewing, and merging similar codes. In the next step, the categories were compared to one another; therefore, those with identical concepts were merged to generate an expanded category, resulting in the emergence of themes.
Based on Lincoln and Guba's concept of trustworthiness, the four criteria of credibility, transferability, dependability, and confirmability were used to make this research trustworthy (18). The researcher had been involved with the topic of the research and the data for two years. Moreover, before and during the interview, he/she maintained a good relationship with the participants to gain their trust. The data which were coded by the researchers were evaluated based on the opinions of other colleagues. For the review, the participants were given a summary of the extracted codes and themes, which were also approved. In addition, maximum variation sampling that helps to relate or transfer the findings to others was used in this study. For confirmability and audit of the research, the researcher recorded and reported the research process accurately.
Result
Based on the results of content analysis, patient favoritism can be categorized under three themes. The emerged themes were as follows: 1) different types of patient favoritism with three sub-themes, 2) reasons for the existence of favored patients entailing three sub-themes, and 3) reasons for receiving favored patients.
Types of Patient Favoritism
Patient favoritism means favoring a patient over others; a patient who is recommended by authorities, colleagues, friends, and acquaintances. This theme was found to be composed of three sub-themes.
1. Prioritized patients
These types of favored patients are prioritized since they have a friend or family member who works in the healthcare system despite the lack of any medical reason for prioritization.
This concept was clearly indicated by one of the nurses:
“Imagine that there are several patients who need magnetic resonance imaging. One of them that is a favored patient is sent in sooner than others and their work should also be done quickly.” (Participant No. 6)
2. Patients receiving better services with higher quality
In addition to being prioritized, favored patients also receive finer services of higher quality, compared to the usual care services delivered in the clinic.
“We must care more about the patients recommended by someone, attend more to them, and meet their needs and desires more than others.” (Participant No. 1)
3. Patients exempted from hospital’s rules and regulations
Every healthcare center has its own set of rules and regulations, such as the visiting hours and dress codes. Some favored patients are exempt from these rules and regulations of the hospital. In this regard, one of the nurses of the neonatal intensive care unit stated:
“In our ward, only parents can come to visit their babies. Sometimes, a grandma comes and insists so much, yet we will not let her enter the ward. But when a baby is favored, her grandma and even her aunts are allowed to visit.” (Participant No. 11)
Reasons for patient favoritism
1. Lack of trust in healthcare system
One of the reasons that people try to make their patients favored in hospitals is the lack of trust in the healthcare system. Regarding this, people try to make their patients favored in order to keep them safe. This was evidently mentioned by one of the participating policymakers:
“I don’t know what is going to happen to my relatives when they go to the hospital! So, I would always call and make sure that they are treated well!” (Participant No. 10)
2. Misuse of government services
Since public hospital services are cheaper than those of private ones, some people hospitalize their patients in public hospitals to provide them with better and higher quality services at a lower cost.
“They told one of our ward’s patients who was waiting for surgery that they had no room at the moment. But then hospitalized the mother of one of the doctors who had a gastrointestinal disorder and was not related to our ward at all.” (Participant No. 8)
3. Scarce medical resources
Due to the scarcity of medical resources in the healthcare system, patients need to wait for a long time to use some services. However, some people who have relatives in the healthcare system are able to use such services sooner than others. One of the healthcare policymakers recounted:
“I had a relative who was in a hospital in town and had to be admitted to the intensive care unit (ICU). He was in the emergency ward for a couple of days, but they told him they had no room and that he had to be transferred to another hospital. I called the hospital manager and told him about my patient. They asked his name and I answered. They called me after an hour and told me that they had taken him to the ICU and he was hospitalized.” (Participants No. 13)
Reasons for accepting patient favoritism
1. Sense of entitlement among healthcare workers
Some people believe that because they are health professionals, they and their family members should benefit from the hospital and receive better services with higher quality. Accordingly, they entitle themselves to be prioritized.
“I'm working in a hospital right now. When I have a problem and need a computerized tomography scan, should I go through the same process as the other patients? No, it shouldn't be like that. I should have some privileges.” (Participant No. 16)
2. Inability to disobey the order of a superior
Nurses and managers mentioned that when they receive orders from their superiors and high-ranking managers about a patient, they cannot disobey and must act as they are told.
“Several times we were ordered to take special care of a patient at night by fulfilling his/her needs as soon as possible. If there is a delay, we will be reprimanded in the morning.” (Participant No. 2)
“When the head nurse, supervisor, and bed manager agree, I (a low-ranking nurse) really can't say no.” (Participant No. 4)
3. Inability to say no to colleagues
Some healthcare system workers stated that they could not say no to the requests of their colleagues or acquaintances. Therefore, they had to provide special services for favored patients.
“When you head for the hospital and your spouse tells you to pay his/her friend a visit at the hospital, you refer to the head nurse, bedside nurse, and everyone else to tell them to take special care of your patient because this patient is one of your acquaintances.” (Participant No. 9)
4. A Win-Win Deal
Some people said that they obey others’ orders about a patient since it would happen to them as well. If they take care of someone else’s patients, they can recommend their own patients in the future. In other words, what goes around, comes around.
“Well, I help somebody in my center, another one helps me somewhere else. I took my patient to Hospital A, and I went to the nursing office and told the supervisor to get my work done sooner.” (Participant No. 16)
Discussion
The results showed that patient favoritism is frequent in the healthcare system of Iran, which can undermine justice in providing healthcare services. In the related literature, the term favored patient is referred to as a “very important person” (VIP) or “recommended patient”. Concept of being prioritized in triage and rationing due to scarce medical resources can be considered regarding the discovered sub-themes of the favored patient. According to Repine (19), moral codes can guide triage; in this regard, both the caregivers and patients must learn the considerations and consequences of triage. When the need for medical care is greater than what can be offered, it is essential to ration care so that those with worse conditions can be treated first. This means that the concept of prioritization has complexities that require ethical and professional principles, without which patient prioritization is unacceptable.
Based on other studies, the VIP who receive higher quality services are divided into different groups. These groups consist of wealthy individuals, politicians, people related to healthcare system in any way, benefactors, hospital managers, prominent characters, celebrities, and healthcare professionals (e.g., physicians and nurses) and their friends or families (20-23).
Regarding the category of reasons for patient favoritism, the high prevalence of medical and pharmaceutical errors in hospitals was reported to be one of the reasons for the lack of trust in the healthcare system. As a result, people try to make their patients favored in order to keep them safe. In a study performed by Haji Babaei et al. (24), the average number of medication errors made by nurses during three months in the selected wards was 19.5 cases per nurse. This rate was reported to be 2.2 (25) and 5.6 (26) in other studies conducted by Mrayyan et al. (2007) in Ordon and Strarrorn et al. (26) in Colorado, United States of America, respectively.
Based on the results of a study performed by Zeraatchi et al. (27), 22% of the patients had experienced at least one medication error and in total, 16 errors were reported per 100 prescribed drug dosages. In another study conducted by Vasin et al. (28), the rate of medication error was estimated at 68.5%. Similarly, a study reported 203 cases of medical errors during 180 h in Shariati Hospital, Tehran (29). Therefore, the reported number of medication and medical errors causes people to lose trust in the safety of their patients in the hospital and increases the probability of patient favoritism.
Furthermore, regarding the sub-theme of scarce medical resources, it seems to be related to the concept of healthcare rationing. Papastavrou believes that since we live in a world with infinite demands and finite resources, health care rationing is essential, inevitable, and morally complicated. He states that the basis for healthcare rationing reflects the values of a society (1). However, the present study found that healthcare rationing does not follow any certain principle and that the nurses rationed healthcare based on their own specific conditions.
Healthcare rationing generally affects other aspects of care; in this respect, the provision of special care to favored patients results in insufficient care delivery to other patients (31). Similarly, some studies have reported injustice arising from medical community by shifting the delivery of special support toward favored patients rather than toward those with a poor financial condition (32).
The sub-theme of the sense of entitlement among healthcare workers is related to the concept of oppression in nursing. Mohammadi et al. (33) reported that most nurses all over the world have experienced oppression. The main features of this phenomenon are unfair treatment, disregard for human rights, and violation of human dignity. In addition, Rooddehghan et al. (34) investigated the relationship between immoral unfair practices and the phenomenon of oppression in nursing.
The sub-theme of inability to disobey the orders of a superior is related to the concept of powerlessness in nursing. A powerless nurse is ineffective, has a lower level of job satisfaction (35), and is more prone to job burnout (36). Nurses should be powerful to be able to influence patients, physicians, and other members of the healthcare team. Lack of power in nursing has been reported to be linked to poor patient outcomes (35). The researchers did not find any study on the two sub-themes of inability to say no to colleagues and the win-win deal. Both of these reasons are contrary to the professional principles of nursing since prioritizing patients to one’s own advantage or that of others is not morally right.
Conclusion
Patient favoritism, regardless of its type, cause, and reason, is in contrast with justice in healthcare and can seriously damage the healthcare system. Consequently, it is essential to explore this issue in other healthcare systems and find relevant solutions.
Research Limitations
In some cases, clinical nurses talked cautiously about the issues that were related to the managers and indicated their concerns by stating “I don't want anybody to know that I said this,” or “If our boss finds out, he/she will get upset”. However, the researcher tried to reassure the participants that they were safe and could trust the researcher. In addition, in interviews with managers, their positions and the fact that the interviews were recorded made them cautious about the issue of justice in healthcare system. Nonetheless, no methods could be employed to resolve this issue.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
The authors would like to thank the School of Nursing and Midwifery of Tehran University of Medical Sciences and all of the participants for their cooperation.
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