HLTH5603 Module 3 ethical framework application example

Fourteen Patients, Two Kinds of Dialysis: Using Accountability for Reasonableness to Decide Whether a Hospital Funds Scheduled Treatment

Student Name

American College of Education

HLTH5603: Legal and Ethical Decision Making in Healthcare Administration

Module 3 Assignment

Instructor Name

January 24, 2028

The Decision

A 400-bed nonprofit hospital in a large city, a composite invented for this assignment, provides dialysis to fourteen undocumented adults with kidney failure. Because they are ineligible for most public insurance, they receive dialysis only when they come to the emergency department with dangerous potassium levels or fluid overload, typically once or twice a week, often requiring admission. The hospital's finance committee has been asked to fund scheduled outpatient dialysis, three sessions a week at a partner dialysis center, through its charity care program. The request would cost the charity budget more in direct payments to the center, though it would reduce emergency and inpatient use.

The clinical evidence is strong. Cervantes et al. (2018) found that undocumented patients receiving emergency-only dialysis had a 14-fold higher adjusted relative hazard of death at five years than those receiving standard scheduled dialysis and spent nearly ten times as many days in acute care. Nguyen et al. (2019) compared scheduled and emergency-only dialysis in a similar population and found that scheduled dialysis was associated with lower one-year mortality, 3 percent against 17 percent, and with lower costs, a difference of about $5,768 per person per month. The evidence answers the clinical question; the ethical question is how a hospital should decide who receives a resource it does not have to give.

The Framework

Accountability for reasonableness, developed by Daniels and Sabin, is a framework for making fair decisions about limited resources when reasonable people disagree about priorities. Daniels (2000) describes four conditions that a legitimate and fair decision process must meet. Publicity requires that decisions and their rationales be publicly accessible. Relevance requires that the rationales rest on evidence, reasons and principles that fair-minded people could accept as relevant. Revision and appeals require a mechanism for challenging and revising decisions in light of new evidence or arguments. Enforcement requires that there be voluntary or public regulation of the process to ensure the first three conditions are met.

The framework suits this decision for a specific reason. Principle-based approaches such as beneficence and justice point strongly toward funding scheduled dialysis, but a finance committee must also weigh other claims on the same charity budget, and principles alone do not tell it how to choose among good uses of limited money. Accountability for reasonableness does not supply the answer; it supplies the conditions under which an answer can be called fair to those who gain and those who do not.

Relevance: Which Reasons Count

The relevance condition changed the finance committee's analysis most. Its first draft framed the question as whether the hospital could afford to extend charity to patients who could not qualify for public coverage. Under the relevance condition, that framing had to be tested against what fair-minded people could accept. Immigration status is not a clinically relevant reason to deny a treatment the hospital already provides in its most expensive and least effective form. The relevant reasons are the patients' clinical need, the evidence that scheduled dialysis saves lives, the cost of each option to the hospital and the opportunity cost to other charity care recipients.

Applied to those reasons, the case strengthened. The evidence on mortality is consistent, and the evidence on cost suggests that scheduled dialysis is likely to cost the hospital less overall, because emergency visits and admissions fall more than outpatient dialysis payments rise. The opportunity cost argument, that the money would come from other patients, weakened once the committee saw that the change was likely to reduce, not increase, total spending on these fourteen patients. Once only relevant reasons were allowed at the table, the decision largely made itself.

Publicity, Appeals and Enforcement

The publicity condition required that the decision and its reasons be stated openly. The committee wrote a one-page rationale explaining that scheduled dialysis would be funded for patients meeting clinical and financial criteria because it improves survival and is expected to reduce total costs, and it posted the rationale within the hospital's financial assistance policy. The committee also decided not to describe the program as being for undocumented patients, but for any patient with kidney failure who has no coverage for scheduled dialysis, which is both accurate and consistent with the relevance condition.

The appeals condition required a process for challenging the criteria. The program established that the number of funded slots would be reviewed each year against actual costs and outcomes, and that clinicians could request exceptions for patients who did not meet the criteria, reviewed by the hospital ethics committee within two weeks. The enforcement condition was met by assigning oversight to the hospital's community benefit committee, which reports to the board and already reviews compliance with the financial assistance policy.

Objections the Framework Had to Answer

Two objections were raised in committee, and the relevance condition required that each be answered with reasons rather than dismissed. The first was precedent: funding scheduled dialysis might draw more uninsured patients with kidney failure to the hospital, increasing future costs. The committee accepted this as a relevant concern and answered it with the program's design, a capped number of slots reviewed annually, rather than with refusal. The second was fairness to other groups: uninsured patients with other chronic conditions, such as cancer, might ask why dialysis was funded and their treatment was not.

That objection is the strongest, and the committee's answer depended on the evidence. Scheduled dialysis is unusual because the alternative, emergency-only dialysis, is already being provided at greater cost and with worse outcomes; funding the scheduled version replaces a worse use of charity resources rather than adding a new one. The committee stated this reasoning in its published rationale and committed to reviewing other conditions where the same pattern might hold. A fair process does not end disagreement, but it makes the reasons for a decision visible enough to be argued with.

The Decision and How the Framework Changed It

The finance committee approved funding for scheduled dialysis for up to sixteen patients, with an annual review of costs, emergency visits, admissions and mortality. Without the framework, the likely outcome was either a quiet exception for these fourteen patients, which would have been fragile and invisible, or a refusal justified by budget pressure and immigration status. The framework produced a decision grounded in relevant reasons, published with its rationale, open to challenge and supervised by an existing board committee. It also produced a program that would survive a change in leadership, because its reasons were written down and its oversight assigned.

Conclusion

Accountability for reasonableness does not tell a hospital what to decide. Applied to the question of funding scheduled dialysis for fourteen uninsured patients, it required the decision to rest on relevant reasons, which excluded immigration status and brought the evidence on survival and cost to the center; to be public, which shaped how the program was described; to be open to appeal; and to be enforced by an accountable committee. The resulting decision, to fund scheduled dialysis under published criteria, is one the hospital can defend to the patients who benefit, to other charity care recipients and to its board.

References

Cervantes, L., Tuot, D., Raghavan, R., Linas, S., Zoucha, J., Sweeney, L., Vangala, C., Hull, M., Camacho, M., Keniston, A., McCulloch, C. E., Grubbs, V., Kendrick, J., & Powe, N. R. (2018). Association of emergency-only vs standard hemodialysis with mortality and health care use among undocumented immigrants with end-stage renal disease. JAMA Internal Medicine, 178(2), 188-195. https://doi.org/10.1001/jamainternmed.2017.7039

Daniels, N. (2000). Accountability for reasonableness. BMJ, 321(7272), 1300-1301. https://doi.org/10.1136/bmj.321.7272.1300

Nguyen, O. K., Vazquez, M. A., Charles, L., Berger, J. R., Quinones, H., Fuquay, R., Sanders, J. M., Kapinos, K. A., Halm, E. A., & Makam, A. N. (2019). Association of scheduled vs emergency-only dialysis with health outcomes and costs in undocumented immigrants with end-stage renal disease. JAMA Internal Medicine, 179(2), 175-183. https://doi.org/10.1001/jamainternmed.2018.5866