| Two newspaper articles summarize the problem, citing the findings of a White House review of the Veterans Health Administration by Rob Nabors, President Obama’s deputy chief of staff, which characterizes the institutional culture as “corrosive” and concludes, “The VHA leadership structure is marked by a lack of responsiveness and an inability to effectively manage or communicate to employees or veterans.” According to The New York Times this culture “has led to poor management, a history of retaliation toward employees, cumbersome and outdated technology, and a shortage of doctors and nurses and physical space to treat patients.” The Wall Street Journal points to “a ‘corrosive culture’ that degraded the timely delivery of care and requires a restructuring to improve transparency and accountability.”
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Ironically, the very programs that made it possible for the VA to outpace other health care institutions in quality care, efficiency, and accountability also seem to have contributed to ethics failure in actual performance. The VA’s focus on quantifiable performance measures and accountability took a life of its own and helped foster the creation of a culture where ethics, integrity, and responsibility were simply overlooked or perceived as an impediment to achieving quality care. For example, the VA required that doctors see patients within 14 days, making “timeliness,” a measure of performance quality. But when it became impossible to meet that requirement, local managers and administrators who were given bonuses for reducing wait-time, falsified the record to make it appeared as if it was met.
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Although not proven effective to date, the VA’s effort to bring ethics into the “organizational mainstream” is laudable. Indeed, the initiative was praised last year in AJOB Primary Research as “groundbreaking in its breadth; its organized systemic approach to ethical practices; and in its broad goals for improving ethics in health care . . .” Changing an ethics culture in any large organization is extraordinarily difficult. I have for 20 years tried to do just that. I have helped make ethics visible and relevant in research, in the day-to-day practice of medicine, and at times in managerial decisions. I did this through personal engagement and continued involvement in diverse educational ethics programs, including ethics consultation, monthly ethics grand rounds, ethics seminars, ethics newsletters, and annual ethics conferences at the cutting edge of science, medicine, and human rights. It is fair to conclude that my efforts in the ethics realm were also ineffective.
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To begin with, the VA may benefit from a complete review of its ethics program to identify its strengths and weaknesses and to discontinue or replace programs that do not work. But no shift in ethics culture seems to be possible without the example of VA leaders to take ethics seriously and recognize that piecemeal solutions to ethical problems are useless, wasteful in a bureaucracy, and, more importantly, potentially harmful to American veterans. VA patients deserve to be cared for in a timely and responsible manner by accountable physicians and nurses, in a fair and equitable environment where ethics, integrity, respect, and human dignity are taken seriously.
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| A team at Duke University in Durham, North Carolina, is set to launch a $40 million clinical trial to explore stem cells from umbilical cord blood as a treatment for autism. But experts caution that the trial is premature.
A $15 million grant from the Marcus Foundation, a philanthropic funding organization based in Atlanta, will bankroll the first two years of the five-year trial, which also plans to test stem cell therapy for stroke and cerebral palsy. The autism arm of the trial aims to enroll 390 children and adults.
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“We hope to demonstrate to people [whether] this is worth pursuing or not,” says principal investigator Michael Chez, a pediatric neurologist affiliated with the Sutter Health Institute, a nonprofit health network based in Sacramento. Chez says he anticipates that some subtypes of autism may respond better to this procedure, and part of the goal of his pilot study is to flag those groups.
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Several clinics outside the U.S. also offer cord blood stem cell treatments for autism. Parents travel to secure the procedure for their children with autism, and some have informally reported signs of improvement.
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