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Quality Improvement Initiatives Raise Ethics Questions

Janice Simmons, for HealthLeaders Media, August 26, 2010

This summer, my family took a sidetrip to Weston, WV—home to what is now called the Trans-Allegheny Lunatic Asylum. This huge, now-empty stone building with the majestic clock tower was closed (as Weston State Hospital) in 1994—and opened for tours several years ago. But the stories it leaves behind can trigger a new perspective on a very modern issue: quality improvement initiatives and ethics.

Construction of the facility—which has been classified as the second largest hand-carved stone masonry building in the world (next to the Kremlin)—started in 1858. The design called for long and rambling wings that could provide therapeutic sunlight and air, in the midst of a bucolic environment for its patients—those identified with varying mental conditions or recuperating from illnesses such as tuberculosis.

But laced into that history of the hospital are stories of early 20th century treatments such as "hydrotherapy" with patients wrapped in sheets and suspended in ice water baths for hours or even days. Or, even darker yet, of transorbital lobotomies performed by medical professionals with ice pick-like instruments in the 1940s and 1950s.

These "treatments" are considered cruel and even barbaric by today's standards. But at the time, they were seen as providing "acceptable" outcomes—at least in the view of various medical professionals—that could improve the life of the patient.

While decades have passed since these treatments appeared and disappeared, an interesting question, though, continues to hover: are all medical organizations making sure that their quality initiatives are meeting ethical standards?

This issue is addressed in a brief "to advance the policy debate" compiled by the Commonwealth Fund. The authors note that over the last two decades, quality improvement initiatives have flourished among hospitals and healthcare systems. But, while enhancing the quality of healthcare is important—and often required by accrediting organizations and others—the process of improvement can raise ethical issues.

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