Psychiatric Annals

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Practical and Ethical Implications of Inpatient Preferential Treatment

Jennifer K. Walter, MD, PhD

Abstract

Many physicians have experienced the changes in protocol that occur when someone who has arrived for medical care is deemed a VIP patient by the hospital administration.

Abstract

Many physicians have experienced the changes in protocol that occur when someone who has arrived for medical care is deemed a VIP patient by the hospital administration.

Jennifer K. Walter, MD, PhD, is a Robert Wood Johnson Foundation Clinical Scholar and General Pediatrician at the University of Michigan.

Dr. Walter has disclosed the following relevant financial relationships: salary, Robert Wood Johnson Foundation; royalties, Georgetown University Press.

Address correspondence to: Jennifer K. Walter, MD, PhD, via fax: 734-647-4844; or email: jenwalte@med.umich.edu.

Many physicians have experienced the changes in protocol that occur when someone who has arrived for medical care is deemed a VIP patient by the hospital administration.

It is intuitively appealing that so-called important patients receive the best care possible and may require deviations from routine treatment protocols.1 This paper carefully examines the different groups who are treated as VIPs and why we are motivated to treat them differently than other patients. Then, it also examines more thoroughly the practical and ethical implications of preferential treatment.

Dilemmas of Preferential Care

VIPs have been described as anyone who has the ability to exert pressure on hospital staff to disrupt the normal course of patient care either by influence upon the hospital administrators or directly because of their fame, position or professional status.2,3 The range of VIPs includes not only celebrities and political figures, but also administrators, medical personnel (and their family members), members of the hospital’s board of trustees when cared for within their own institutions, and wealthy individuals perceived to be possible future donors.

What these individuals have in common is an ability to elicit changes in standard protocols and receive preferential care when compared with other patients. Hospital administrators may defend the involvement of multiple, senior physicians caring for some VIP patients because they have a higher profile and any mistake can have a significant financial or public relations impact on the hospital. Because so much is at stake, they argue, it is appropriate to be more cautious and conservative than with other patients; tolerance for clinical error is lower.4

Management of potential error and the resultant bad press is not the only argument for preferential treatment, however. The converse argument used to justify preferential treatment of celebrity and wealthy VIPs is that the hospital benefits when the influential and powerful have had the best possible care and overall experience within the hospital system. This argument is used, for example, to defend access to the emergency department (ED) outside of the typical triage system or requests for private rooms, personal chefs or physicians. Administrators reason that, if VIPs are made to feel that they are incredibly important and have received exceptional care, they will bestow financial benefits upon the hospital directly, or by publicly endorsing the institution, thus helping its fundraising efforts.

This argument takes the form of a utilitarian claim that beneficial outcomes justify the means used to achieve them. Because the hospital administrators are attempting to preserve and enhance the reputation and financial status of the hospital, allotting additional resources to VIPs would thus be considered worthwhile and morally acceptable. The expectation is that offering preferential treatment to VIPs will encourage them to make generous donations. This, in turn, would benefit other patients, because the facility would then have the resources to expand services and provide more charity care.

Some authors argue that the special status of these patients justifies minor concessions, eg, extended visiting hours or private rooms,5 and that it is appropriate for care staff to recognize their different needs6 using “need” as the basis for dispensing scarce resources.6 Whereas EDs typically triage based upon medical need, preferential treatment for VIPs is thus based on need for recognition, regardless of the degree of medical need they may have. It then becomes the care team’s responsibility to offer resources to those perceived to have the greatest need and to do it as efficiently as possible. Because VIPs are accustomed to being treated preferentially and their need for status is stronger than the average patient, the hospital is expected to work to accommodate those needs whenever possible, balancing them against the needs of others.

Another argument would allow preferential care but restrict it to the small group of patients who are high-level politicians or leaders. This argument acknowledges that such individuals possess broad social value and that it is therefore in society’s interest (rather than only the patient’s) to ensure they receive prompt, excellent care so they can quickly return to public service. In this situation, it is not the VIP status that prompts a moral claim for preferential care, but the society’s dependence on this individual’s contribution to the functioning of a society. There are few roles that qualify for this type of privilege, but those might include the top political leadership (or perhaps military leadership in times of war).

Finally, special treatment might be justified on the basis of confidentiality. This right is accepted for all patients, but because there is more interest and scrutiny in the care of VIPs by the media, administration, or by the VIP’s own family members and entourage, the hospital may be under an obligation to make additional efforts to protect the patient’s privacy.7 For celebrities, this may require providing more services in the patient’s room to avoid moving them throughout the hospital. For physician-patients, it may require a reminder by the hospital administration that while a friend/colleague is hospitalized, it is inappropriate to request information about patients from the staff caring for them. While some would consider the extra measures necessary to maintain confidentiality preferential treatment, many argue that it is just meeting the minimum standard of protecting confidentiality and should be done for any patient who requires it.

Ethical Considerations

The first argument favoring differential treatment of VIPs is the utilitarian claim that the hospital will benefit to the largest degree if its VIPs receive excellent care because they will go on to support the hospital financially and with good publicity. However, if VIPs receive substantially different care than their non-VIP counterparts, it seems that the VIP’s endorsement would be based on false information.

Even if the hospital were to receive increased funding as a result of a VIP’s donation or good publicity, this does not mean that the funds will be directed to improving the care of regular patients; such a windfall might instead be channeled into projects aimed at increasing the number of privately insured patients in areas most lucrative to the hospital rather than those most needed in the community.

If the hospital truly wanted to show its strengths, it might instead serve VIPs the same as the rest of their patients, demonstrating commitment to excellent care for all patients.8 If deficiencies or errors occur, the VIPs are then best positioned to advocate for essential changes to ensure better care for everyone.9

Also, the argument that other patients will benefit from preferential care of VIPs overlooks the unfairness to those patients who are forced to wait longer. When VIPs are seen more quickly and require more senior staff to meet their needs, other patients (who may even be more acutely ill) suffer from the delay in care.

The premise that VIPs should be given preferential treatment based upon their social status has been attacked on two grounds.10 First, although at least some VIPs may have a greater expectation that their needs should precede those of others, this is not the same as having more unmet medical needs that should be accommodated. In fact, VIPs in general are very privileged and have the skills and power to advocate for themselves quite effectively.10

However, fairness would dictate that social status in other aspects of life should be carried into the health care sphere.10 While recognition may be paid appropriately to some individuals in other spheres, this recognition should not necessarily dictate how health care is distributed: Public resources significantly underwrite medical education and research, and while private hospitals are able to earn profits, this public contribution ties the allocation of health care to the greater social good.

Health care, therefore, should be distributed on a standard of fairness that does not entitle those with social status to more health care resources. It is not unjust that some have more than others; it is unjust when someone who has higher standing in one aspect of life is then offered privilege in another.10 In other words, while VIPs may be due appropriate respect for their fame, wealth, or accomplishments, these characteristics should not influence how we allocate health care resources.

Practical Considerations

Providing preferential care for VIPs is assumed to be providing superior care. However, there is good evidence that changing routine care protocols can lead to worse care: Attempts to avoid embarrassment or uncomfortable procedures can result in missed diagnoses and even adverse outcomes. There has been speculation, for example, that Eleanor Roosevelt’s diagnosis of miliary tuberculosis was missed because she received only a bone marrow aspirate and was spared a bone marrow biopsy that would have been more painful, but would have given the correct diagnosis.11 As a result, she received treatment with steroids, which hastened her death.

Similarly, worse care may be offered physician-patients because physician-patients may be assumed to already have enough information about his or her illness; in addition, the caregiver-physician may defer to the patient for his or her own management.

Other problems can arise at teaching hospitals when only the most senior physicians are allowed to manage the VIP, excluding contributions from residents and medical students. Clinical experience may not suffice to navigate the different departments of the hospital or substitute for practical knowledge about how to obtain procedures. In addition, a senior physician’s technical skills may have become rusty due to lack of recent practice, whereas residents are generally the most familiar with the protocols necessary to ensure timely patient care while navigating the hospital bureaucracy.12 Additionally, when administrators emphasize the importance of providing preferential care for VIPs, staff responsible for direct patient care may become more stressed and resent the implication that their typical care is not good enough. This extra emphasis on “excellent care” can also further undermine physicians’ and nurses’ confidence in their care.5

There are ethical implications to offering what is known to be inferior care, and hospital administrators should be aware that this may be the consequence of demanding a deviation from standard operating procedures. In fact, some have argued that VIPs should be given informed consent when provided with special care because there is the increased risk of them receiving worse care, even if unintentionally.2

All of these issues may be worsened when the VIP presents for psychiatric care. In particular, there may be pressure from the VIP for the psychiatrist to take on a subjugated role.7 If the psychiatrist either cedes control to the patient too readily, or becomes overly controlling, the therapeutic relationship may be undermined.

This has, on occasion, led to situations in which VIPs were given special privileges on the inpatient wards that endangered their safety and made achieving the therapeutic goals significantly more difficult.5 Additionally, when nonstandard limits or restraints are put on patients on the psychiatric floor, staff may become resentful and can withdraw from the care of these patients.

Conclusion

For many, it is intuitively appealing to change standard operating procedures to offer VIPs more efficient, personalized, experienced, and private care. Whether it is resentment from staff for having been asked to do things differently, or avoiding medically appropriate but “inconvenient” questions, VIPs receiving preferential care can be at risk for worse care.

Utilitarian arguments and those defending VIPs preferential treatment can be countered by appeals to fairness. VIP status is not relevant to the just distribution of health care service. Confidentiality requirements may dictate different treatment in the case of VIPs, but this deviation from standard care is based on all patients’ rights to privacy.

References

  1. Mellick L. VIP patients should be treated differently. ED Manag. 2000;12(8):90–92.
  2. Schenkenberg T, Kochenour NK, Botkin JR. Ethical considerations in clinical care of the “VIP.”J Clin Ethics. 2007;18(1):56–63.
  3. Weiss YG, Mor-Yosef S, Sprung CL, Weissman C, Weiss Y. Caring for a major government official: challenges and lessons learned. Crit Care Med. 2007;35(7):1769–1772. doi:10.1097/01.CCM.0000269937.91957.44 [CrossRef]
  4. What if your ED misdiagnoses a public figure? Here’s how to handle VIPs. ED Manag. 2000;12(11):121–124.
  5. Weintraub W. “The VIP Syndrome”: a clinical study in hospital psychiatry. J Nerv Ment Dis. 1964;138:181–193. doi:10.1097/00005053-196402000-00012 [CrossRef]
  6. Strange RE. The VIP with illness. Mil Med. 1980;145(7):473–475.
  7. Parker G. Should a psychiatrist give the ‘special patient’ VIP treatment?Acta Psychiatr Scand. 2009;120(6):411–413. doi:10.1111/j.1600-0447.2009.01497.x [CrossRef]
  8. Hospital treats patients and families like VIPs. Healthcare Benchmarks Qual Improv. 2005;12(6):66–68.
  9. Diekema DS. It’s wrong to treat VIPs better than other patients. ED Manag. 2000;12(8):92–93.
  10. Diekema DS. The preferential treatment of VIPs in the emergency department. Am J Emerg Med. 1996;14(2):226–229. doi:10.1016/S0735-6757(96)90137-0 [CrossRef]
  11. Lerner BH. Revisiting the death of Eleanor Roosevelt: was the diagnosis of tuberculosis missed?Int J Tuberc Lung Dis. 2001;5(12):1080–1085.
  12. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. 2011;78(2):90–94. doi:10.3949/ccjm.78a.10113 [CrossRef]
Authors

Jennifer K. Walter, MD, PhD, is a Robert Wood Johnson Foundation Clinical Scholar and General Pediatrician at the University of Michigan.

Dr. Walter has disclosed the following relevant financial relationships: salary, Robert Wood Johnson Foundation; royalties, Georgetown University Press.

Address correspondence to: Jennifer K. Walter, MD, PhD, via fax: 734-647-4844; or email: .jenwalte@med.umich.edu

10.3928/00485713-20111229-07

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