Looking toward the horizon at the financial whirlwind approaching academic medical centers, medical ethicists fear they may be among the first sacrifices to the gods of mammon.
Figures on the number of bioethics programs in the United States were not available, but most are based at academic medical centers. As various payers reduce their funding for these expensive institutions, their administrators will look for the easiest budgets to cut. Bioethics programs could be at the top of the list.
"The overwhelming majority of bioethics funding is soft," said Arthur Caplan, director of the Center for Bioethics at the University of Pennsylvania in Philadelphia. "This is a very perilous situation."
By "soft" funding, Caplan meant that many medical ethics programs depend on money set aside by the dean or from other discretionary sources or federal grants that could quickly dry up. "Hard" money is allocated every year by the central university administration.
In many cases, a research grant to a medical school contains a certain percentage for overhead. The dean may move some of that money toward bioethics. "So indirectly, when physiology or pulmonology get a grant, it benefits bioethics," Caplan said. He fears, though, that bioethics will come to be viewed as strictly overhead, therefore expendable.
"There's a fragility about these programs," said Jonathan Moreno, director of medical humanities at State University of New York Health Science Center, Brooklyn. "They are considered marginal to the mission of the medical school in many places. Their future is dependent on having a very supportive senior administration."
Myra Christopher, president of the Midwest Bioethics Center in Kansas City, Mo., said: "Unfortunately there are lots of people who believe ethics are fluff, and not substantive. I think the whole bioethics movement is at risk. People (in the medical centers) are so threatened by survival issues, it's harder to get them to think on a higher plane."
State-funded universities are feeling the crunch already. The governor of New Mexico has ordered the state's university to cut expenses 2.5%. "To the extent that institutes and centers depend on university funding for their existence, it's going to be a hard road," said Joan McIver Gibson of the Center for Jurisprudence and Ethics.
The New Mexico ethics program is in better shape than many, she said, because it has avoided building up a center with attendant overhead costs.
"For example, I have an appointment in the school of medicine and teach there," Gibson said. "Nursing has given us a room, and supports an office manager. The vice president has given us a very modest budget. And the law school contributes faculty as well, so we all have homes in different places. We could almost exist on a sidewalk."
The University of Washington's bioethics program is a humanities department in the medical school, which has advantages and disadvantages.
"Both the government and private agencies that fund research like to see something with tangible results," said Julie Cheetham, administrator of the Department of Medical History and Ethics. "They like lab research and clinical research. The humanities areas, including ethics, are a lot less tangible. Sometimes there is a product, but often the product is ideas. It's not something you can put your fingers on and say, I funded that."
Washington state has traditionally been the financial mainstay of the humanities, but recent cutbacks "affected our budget severely," Cheetham said. "We have been able to maintain the same number of classes and students, but the faculty have to do more of their own secretarial work, typing manuscripts, answering their own phones. It puts a constraint on their time."
Peter C. Williams, at SUNY Stony Brook, said the ethics program at the medical school there has had a stable budget for five years. "We've gotten steady and consistent support from the dean," who contributes half of the $500,000 total budget. However, "If he decides he would rather spend the money on something other than us, he can do that."
Contrary to Caplan's reasoning, Williams said that funding is very secure because "our program is thoroughly integrated into the rest of the curriculum. All of us work like dogs. It would take a sea change in the institution for us to lose our funding." Williams' salary is paid by the taxpayers. "Working in the state of New York is trouble, because every 10 years or so the state goes belly up," he said. The new Republican governor, George Pataki, is facing a huge budget deficit, which he wants to make up "by whacking the state university."
But, Williams said, whacking the ethics program "wouldn't gain enough to make it worth his while. It's the benefit of living in the little house in the back 40. There's no point in throwing me off."
The Midwest Bioethics Center is one of the few not connected with an academic institution. Still, it feels the pinch. Christopher said it draws funding from hospitals, managed-care companies, insurers, nursing homes and individuals, and is not as susceptible to declines in state funding. But the cuts elsewhere could have an impact.
"One of our clients, a hospital, sent me an internal memo the other day," she said. "They believe their budget will be cut 38%. When people are looking at those kinds of cuts, will they pay annual membership dues?"
At the same time, cutbacks in Medicare and Medicaid means "more real human need is being dumped into the not-for-profit sector. It is very hard for us to fund raise against organizations that have a very direct emotive appeal," Christopher said.
For ethicists to survive, they need to get out of their ivory towers and drop their dispassionate academic remove, Christopher said. She's trying to sell consulting services to enhance hospitals' and health plans' ethics standards.
"I say, it's going to help reduce legal exposure," she said. "It helps you to hire the best clinicians, and nurses and companies. And it satisfies accreditors. It's a marketing tool for sophisticated purchasers. I really do believe good ethics is good business."