Abstract
Background:
Not all patients are considered equal. For patients who are considered to be “very important persons,” care can be different from that of other patients with advantages of greater access to resources, special attention from staff, and options for luxurious hospital amenities. While very important person care is common and widely accepted by healthcare administration, it has negative implications for both very important person and non-very important person patients, supports care disparities and inequities, and can create serious ethical dilemmas for healthcare professionals. Very important person care can also result in negative care outcomes for its recipients.
Objective:
This article sought to explore the implications and ethical considerations of very important person care within the context of United States healthcare system, and integrate bioethical principles and American Nurses Association Code of Ethics for Nurses to influence recommendations for managing ethical dilemmas associated with very important person care.
Method:
A synthesis of the literature on very important person care was undertaken for this article.
Ethical considerations:
Ethical conduct was considered and respected when performing the literature review, referencing sources, and establishing authorship.
Findings:
According to the published literature, very important person care bares both positive and negative implications for patients, and negative implications for nurses. Nurses are the most affected by the demands from their administrators to provide special care and attention to patients in the “very important person” category and their families. Very important person care can be disruptive, disorienting, challenging, and stressful to nurses.
Conclusion:
While physicians and other healthcare professionals have commented on very important person care, limited work has been done in nursing. There have not been any empirical studies on very important person care. Therefore, in order to minimize the negative implications of very important person care, studies of this phenomenon are warranted. Exposing very important person care is important in the development of an ethical healthcare system. Moreover, understanding the ethical principles surrounding the concept of very important person care will empower nurses to effectively manage conflicts and ethical dilemmas that arise with very important person care.
Introduction
The presence of the very important person (V.I.P.) phenomena raises questions about the quality and safety of care delivery. The care of patients who are considered to be V.I.P.s can be different than that of other patients. V.I.P. care often provides greater access to healthcare resources, special attention from staff, and luxurious amenities. Despite these benefits, and the wide acceptance of V.I.P. care by healthcare administrators, V.I.P. care can have negative impact on V.I.P. patients, non-V.I.P. patients, and healthcare professionals. V.I.P. care supports healthcare disparities and inequities, and can create ethical dilemmas for healthcare professionals. Nurses are the most affected by the demands from their administrators to provide special care and attention to patients in the V.I.P. category and their families. The concept of V.I.P. care can be disruptive, disorienting, challenging, and stressful to nurses.
The literature on V.I.P.s in healthcare includes expert opinions, editorials and publications from physicians and other healthcare professionals. Very limited published nursing literature exists. Other than a few surveys, there have not been any empirical studies to validate the quality of V.I.P. care, its impact on other patients, or nurses’ attitudes toward caring for patients in the V.I.P. category. The issues and ethical dilemmas on providing V.I.P. care have remained a quiet, unspoken reality in nursing. Understanding V.I.P. care, the good and the bad, its implications for all patients and staff, and the influence of healthcare administrators on this issue, can enhance nurses’ response and management of the challenges that arise from V.I.P. care. This article will integrate bioethical principles and the American Nurses Association (ANA) Code of Ethics for Nurses to influence the recommendations for managing ethical dilemmas associated with the provision of V.I.P. care in the United States with some references to other systems.
Background
In the common vernacular, V.I.P. is defined as a “very important person, especially a high-ranking guest,” or a “very important person or a famous or important person who is treated in a special way.” 1 Synonyms of V.I.P. include “celebrity” and “dignitary.” 1 The term “V.I.P.” was first published in healthcare literature by Weintraub 2 where the term “V.I.P.” referred to patients with mental illness who used their personal or professional influence to exert uncommon pressure upon the care team of a psychiatric hospital. Since its introduction to healthcare in 1964, the term V.I.P. has remained in the healthcare taxonomy.
Within healthcare, the term has been used as an acronym for a very important patient, very influential patient, very intimidating patient, or a very impressive patient. 3 –5 Smith and Shesser 6 defined V.I.P. as “anyone whose presence in the hospital, by virtue of fame, position, or claim on the public interest, who may substantially disrupt the normal course of patient care.” An “influential patient whose individual attributes and characteristics (e.g. social status, occupation, position) coupled with their behavior, have the potential to significantly influence a clinician’s judgment or behavior” is also referred to as a V.I.P. 7 Mellick 8 reports that V.I.P.s are patients who present to the hospital with special needs due to their positions of authority, organizational rank, and celebrity status.
In many instances, V.I.P. status is conferred because of the potential of large donations to the institution. Geiderman et al. 9 reported that philanthropists are categorized as V.I.P.s due to their financial influence on the organization. Another category of V.I.P. is identified as “potentates,” category of individuals who are well-known, very well-off, well-connected, “very impressive,” very wealthy, and with possible financial ties to the organization. 3 The potentates may be able to convince the organization to provide special care, or by making subtle or unsubtle hints about connections, or threats to negative publicity and legal consequences. 10
Patients are classified as a “V.I.P.” based on the following factors:
Socio-economic status;
Relationship with the healthcare organization;
Politicians;
Board member status;
Actual or potential donors;
Hospital administrators;
Prominent community individuals;
Healthcare professionals including nurses and physicians;
Celebrities;
Friends and family of patients in the V.I.P. category. 3,9–11
It is well understood by healthcare professionals that patients in the V.I.P. category have the ability to influence their care based on their status and behaviors. 7 The phenomenon of V.I.P. care has been widely accepted in healthcare, and nurses are often called upon to deliver “special” care to “V.I.P.” patients. Diekema 12 and Guzman et al. 11 confirm that patients with V.I.P. status often receive preferential treatment within the medical setting. Concerns have arisen that V.I.P. care poses risks for both the patient and the nursing staff. Patients who receive V.I.P. care are at greater risk for negative health outcomes than non-V.I.P. patients due to over or underutilization of resources. V.I.P. care can result in dilution of scarce nursing resources. Requiring care that is outside of the standards and norms can lead to increased workload, job dissatisfaction, burnout, and turnover among nurses. Many studies have already confirmed that the nursing staffing is inadequate for everyday provision of high-quality care. 13 –15 V.I.P. care could further contribute to this problem.
Method
A comprehensive literature review was conducted for this article. The keywords used for the search with Boolean phrases included “V.I.P. patient, V.I.P. care, very important person, special patient, nursing care of V.I.P, celebrity patient.” This search was undertaken in all available EBSCOhost databases, OneSearch, Google Scholar, and PubMed. The search was limited to publications in the English language. The initial search resulted in 38 articles. Articles were excluded if they did not discuss healthcare delivery to V.I.P. patients or were duplicates. Twenty-five articles, including editorials, were analyzed and synthesized. Of the 25 articles, 19 were written by physicians, 1 by nurses, and the remaining 5 were written by advisors and editorial boards. One of the articles was a study on rationing of nursing care where the care of V.I.P. patients emerged in the findings. Another article included results from surveys of providers regarding their exposure to V.I.P. care. There were no published empirical studies on V.I.P. care.
Descriptions of V.I.P. care
Although it is not well known by the general public, different forms of V.I.P. care are common. Two groups of V.I.P. patients are most commonly referred to in the literature. The V.I.P. classification where individuals pay for better services or utilize centers that offer private services to anyone who is able to afford them. The second group of V.I.P. patients often use their status or power to exert pressure for additional services within a general care setting. The top 15 hospitals ranked by US News and World Report, reported to having luxury treatment options for additional, non-reimbursable fees. 16 In some hospitals, patients in the category of “V.I.P.” receive care on units with special amenities. Other hospitals offer the option to pay out-of-pocket for special treatment in luxurious rooms with private nurses and ancillary staff. In a survey of 160 hospitalists across 8 different hospitals, 78 respondents reported that V.I.P. services were offered at their hospitals, including special menus, private or luxury-style rooms, and personal care attendants. 17 While these V.I.P. options are common, they are different from the V.I.P. care in the general hospital units in that these special care and luxurious options can be made available to anyone with the financial ability to pay out-of-pocket to receive them. The exclusive V.I.P. options are also predesigned as to not deplete resources from other patients. Often, the patients on these V.I.P units, such as celebrities, also require extensive security presence for their protection and privacy from the general public.
In contrast to the units that specialize in V.I.P. care provision, the general hospital units that receive patients in the V.I.P. category face distinct challenges. V.I.P. patients in this category can abuse their positions for better access to services. When a V.I.P. patient is admitted to a general floor, the resources of the floor can be compromised. Nursing staff and supplies can be diverted to the V.I.P. at the expense of the other patients. Because they are expected to provide special care to V.I.P. patients, healthcare professionals have reported feeling pressure to expedite their care, and eliminate any wait time for services. 17 While little is known about the nursing response, more than one-third of the 160 hospitalists surveyed reported feeling pressure from the hospital staff to provide special treatment to V.I.P. patients. 17 A survey of medical directors in Connecticut posited that there was a common and justifiable “widespread agreement” to expedite the care for V.I.P. patients in the emergency department; it was believed that if V.I.P.s had a positive experience, it would benefit the hospital. 18 Hennessy-Fiske 19 reported that 84% of 100 emergency department directors surveyed reported that they had given additional attention to a V.I.P. patient. In the emergency departments, patients with V.I.P. status pose increasing demands on the staff, such as expedited triage, elimination of wait times, faster turnaround for tests, special requests for increased privacy, and accelerated room placement. 8
Issues with V.I.P. care outcomes
The common perception is that V.I.P. care is superior to that of non-V.I.P. counterparts; however, V.I.P. patients can receive care that is suboptimal and often experience worse medical outcomes than non-V.I.P.s. 2,3,9,11,20 V.I.P. treatment can lead not only to negative patient outcomes but also death. 9 This can be attributed to the “VIP Syndrome” which occurs when pressure is imposed on healthcare workers to provide special treatment, to bend the rules, and to change clinical practices. 2,11,20,21
Another contributor to negative patient outcome involving V.I.P. care is known as the “star-struck” phenomenon which occurs when a well-known celebrity in care causes “more intense and even specific inappropriate reactions in those around him” (p. 12). 20 An example of negative outcome related to the “VIP syndrome” and the “star-struck” phenomenon is the death of Eleanor Roosevelt from tuberculosis when she was misdiagnosed with aplastic anemia and treated with steroids. 9
Over attention to minor complaints received by V.I.P.s can lead to magnified clinical exposure with excessive interventions, diagnostic studies, and treatment resulting in unexpected and counterintuitive risks.
22,23
Inappropriate allocation of resources to V.I.P. patients include the excess ordering of laboratory tests, imaging, and consultations that may not be clinically indicated.
9,3,17,24
V.I.P. care can also result in extended lengths of stay. It was reported that 57% of 166 hospitalists surveyed reported that they would extend the length of stay for a hospital board member who voiced concerns about discharge; 61% of the respondents based their decision on the patient’s connections to the hospital.
17
The excess care provided to V.I.P. patients can lead to incidental findings that may be clinically irrelevant, and provide unnecessary exposure to radiation, thereby increasing the risk for patient harm.
24
Surgeons have identified higher post-surgical morbidity and mortality in “special” patients; this is likely attributed to surgeons being more “thorough” than the norm, for example, using more sutures than the standard.
25
The
Conversely, V.I.P. care can also cause harm to patients because of underutilization of resources. The healthcare professionals’ anxiety and fear about causing inconveniences for patients in the V.I.P. category have been found to cause underutilization of resources, which can lead to incomplete medical screening, misdiagnoses, omitted diagnostic procedures, and inappropriate treatment. 10,22,27,28 Despite these risks, healthcare professionals, including nurses, are routinely asked to bend the rules to providing V.I.P. care.
Implications for nursing practice
Weintraub 2 cautioned that the pressure experienced by staff from V.I.P. patients and their families often lead to staff withdrawal and therapeutic failure. In one of the few articles in the nursing literature, Rooddehghan et al. 29 reported in a qualitative study of rationing of nursing care that V.I.P. patients were viewed as more important and as such, received higher quality care. For example, V.I.P. patients were highlighted during handoff, nurses were asked to “answer V.I.P. patient calls faster,” and they were forced by their management team to provide more time, and accurate and timely care to V.I.P. patients. 29 Caring for V.I.P. patients has even been proposed as the third cause of nursing care rationing. 29 This adds to the existing nursing rationing practices. As reported by Schubert et al., 30 nurses have rationed attention to patients by withholding or improperly delivering certain aspects of care. Rationing practices have the potential to affect the safety and quality of care delivery. 31 It is also reported that attempts by staff to limit contact with V.I.P. patients can result in missed care. 23 Preferential treatment of V.I.P.s can be associated with a desire for staff to receive recognition and respect while potentially avoiding blame for negative outcomes. 10
A study in Ghana examining differences in patient-centered care between private and public inpatient hospitals, and whether patient satisfaction differed between patient groups found that physicians demonstrated stereotypical behaviors toward public hospital patients, thereby suggesting care inequities between patients of high and low socioeconomic status. 32 Some of the inequities of this study were that the physicians’ interactions, emotional support, and provision of dignified care were considerably better for private hospital patients; furthermore, patients in lower economic status did not receive satisfactory care and attention as compared to the private patients who received significantly more time with the physicians and empathetic care. 32 While the concept of V.I.P. care nor its impact on nursing surfaced in this study, it bears similarities to V.I.P. care as most patients in this category may have a higher socioeconomic status than the general population.
Bioethical considerations
The sense of urgency created by administrators upon the arrival of a patient who meets the V.I.P. classification generates anxiety among the care team. 10,23,33 Beyond anxiety, caring for V.I.P. patients raises important ethical concerns. As a result, nurses can experience moral distress when caring for this population. Bioethical principles that are significant to the practice of V.I.P. care are as follows: autonomy, nonmaleficence, beneficence, justice, and privacy.
Respect for autonomy
Geiderman et al. 9 argue that patients have the autonomy to make their own decision regarding their medical care. This, however, does not include the right to request and receive “special” or preferential treatment over other patients. Autonomy is the notion that individuals who are competent have the right to self-determination or self-governance, and it is expected that healthcare professionals would respect this right. 34 Beauchamp and Childress 35 further add that personal autonomy includes self-rule that is free from interference by others, and limitations that prevent informed choices. The principle of autonomy can impact nursing care delivery for individuals with V.I.P status who could be accustomed to self-direction, thereby being reluctant to receiving care while still making demands for special treatment. While there is a duty to respect individual autonomy, we can do so as “long as their thoughts and actions do not seriously harm other persons.” 35 It is important that nurses understand that V.I.P. patients have physical and psychological needs, like the general patient populations. As such, they should be accepted and respected without any resentment. The focus should be on providing safe, quality, and equitable care.
Nonmaleficence
The principal of nonmaleficence “obligates us to abstain from causing harm to others.” 35 Physicians and nurses have a duty to prevent harm from patients as also mentioned in the Hippocratic Oath, and the Nightingale Pledge that both state “above all do no harm.” The art of nursing is “based on caring and respect for human dignity” (p. 11). 36 It is well documented in the literature that V.I.P. treatment can impose potential harm to V.I.P. patients as well as non V.I.P. patients. Examples of potential harm include the under- or over-utilization of resources and treatment of V.I.P. patients; these can lead to misdiagnosis and overexposure to unnecessary radiation. Non-V.I.P. patients can be harmed by the reallocation of resources to meet the special needs of V.I.P. patients. Guzman et al. 11 posit that caring for V.I.P.s can result in pressures on the healthcare team to bend standard of care rules. Social workers have also commented on V.I.P. care. In an editorial, Kirshblum et al. 37 discussed the provision of differential care based on social or socioeconomic status in the rehabilitation setting; they claimed that the differential care likely begins at the macro level percolating to the clinicians. The substandard practice can lead to patient harm. In addition, the pressures exerted by administrators on staff can cause tension and conflict during the care of the V.I.P. patient due to differences in goals. 10 Therefore, the care and treatment of a V.I.P. patient should not never be predicated based on their status.
Beneficence
Beneficence, the principle that provides guidance to take action to benefit others includes protecting and defending the rights of others, preventing harm from occurring to others, and removing conditions that will cause harm to others. 35 Physicians and nurses have a duty to deliver care that is beneficial to patients, while promoting their welfare and “do good.” It is not ethical to medically provide “more good” for some patients over others. 9 Although that is the unspoken goal in V.I.P. care. Providing “more good” for some patients over others can limit resources and care from the general patient population. This can lead to negative outcomes and harm to non-V.I.P. patients. Peirce and Smith 34 posit that nurses have an “unspoken obligation to work towards the welfare of the patient” (p. 11). Nurses have a duty to be beneficent to patients in their care. The care provided should be based on patient needs, not on their status. The temptation or fear-guided motivation to treat V.I.P. patients differently should be avoided.
Distributive justice
Nurses want optimal treatment for all their patients. V.I.P. care can conflict with the principle of distributive justice which refers to the fair, equitable, and appropriate distribution of burdens and benefits. 35 This principle posits that equality in healthcare is a right for all. 34 The consideration of various theories of distributive justice, including the principles of egalitarian, utilitarian, communitarian, libertarian, well-being, and capacities suggest heterogeneous recommendations regarding distributive justice in V.I.P. care.
The egalitarian view of distributive justice holds the belief that all human beings must be treated equally because they are created as equals, and have equal moral status. 35 This negates the practice of V.I.P. care which does not always treat everyone as equals. In contrast to the egalitarian principle, the utilitarian principle of distributive justice posits that healthcare providers should aim to produce a maximum balance of positive value over disvalue, and when only undesirable outcomes can be achieved, efforts should be made to provide the least possible disvalue. 35 The good should outweigh the bad. 35 When resources are shifted from the general patient population to accommodate the special needs of a V.I.P. patient, this can lead to the most disvalue and least balance of positive value.
An inadvertent result of V.I.P. care is nursing care rationing. The concept of rationing is described as withholding or improperly delivering some aspects of care. 31 This is often due to limited resources, such as human resources. In a study by Rooddehghan et al., 29 it was found that V.I.P. patients were prioritized for the receipt of nursing care and high-quality services. While care rationing may be advantageous to V.I.P. patients by virtue of being prioritized for care, it poses risks to the non-V.I.P. patients with potential for compromised safety, quality, and decreased satisfaction.
The communitarian principle argues for the common societal good as opposed to individual good or right. 35 Providing expedited care to a V.I.P., for example, who may be a societal leader, such as the president of a country may be acceptable under the communitarian principle as their well-being may be essential to society.
The libertarian principle does not support the production of just and equal distribution of health resources; based on this principle, rights and justified claims to healthcare cannot be based on justice. 35 The well-being principle of justice focuses on the achievement of well-being and the right to health, not healthcare; it is concerned with six core dimensions of well-being: health, personal security, reasoning, respect, attachment, and self-determination. 35
Finally, the capabilities principle posits that the basic moral significance lies on the capability to reach a state of proper functioning and well-being. 35 According to this principle, society must not interfere with an individual’s development of their core capabilities, and society must provide, when needed, resources that are necessary to allow an individual to be capable of living appropriately, including healthcare and non-discriminatory institutions. 35 V.I.P. care does not conform to the principles of well-being and capabilities as it can impact the well-being, respect, attachment, and self-determination of the general population. Contradictory to the capabilities principle, V.I.P. care can interfere with the general patient population’s capability of living appropriately by not always providing healthcare resources when needed. V.I.P. care, however, conforms to the libertarian principle which justifies claims that healthcare cannot be based on justice.
Just as some of the principles of distributive justice can be supportive of V.I.P. care, while others are dismissive of this care concept, V.I.P. care can lead to both advantages and disadvantages to its recipients and deliverers. The material principles of justice specify characteristics for equal treatment based on substantive properties for distribution whereby fundamental resources, such as healthcare, are distributed based on need, and that without the resource, an individual could suffer harm or detrimental effects. 35 Based on the foundational fairness and equality emphasis of distributive justice, healthcare facilities should provide the same quality of medical treatment to all individuals without regard to status. One can argue that the expeditious triage and care delivery of a V.I.P. is beneficial to the financial gain and public reputation of the institution, but it must be asked “At what expense to other patients and staff?” This is analogous to the recent allegation that an airline had pressured its crew to work over 48 h for the corporations’ financial gains despite the potential safety risks to its passengers. 38 The potential financial benefits of caring for a V.I.P. should not outweigh the quality and safety of care of the general population or our professional standards. All patients are “very important.” The provision of medical treatment would be based solely on medical needs with the understanding that those needs are not always equal. V.I.P. care can negate the principle of distributive justice if it provides different levels of benefits and care based on factors unrelated to healthcare needs.
Privacy
Patients have a legal and moral right to privacy. The term privacy bears its roots from the fundamental human right to “liberty” that gives all human beings the freedom of their person. Respect of autonomy includes the respect for the privacy of others. Beauchamp and Childress 35 define privacy as a “state or condition of limited access…which involves the agent’s right to control access” (p. 312). It is further argued that the principles of respect for autonomy and rules of privacy also support the rights of confidentiality and vice versa. 35 Various forms of privacy exist. In biomedical ethics, informational privacy limits access to the person, physical privacy emphases on the person and their personal space, decisional privacy refers to personal choices, proprietary privacy interests in property interest of the person, and finally, relational privacy which covers intimate relations. 35 The Health Insurance Portability and Accountability Act (HIPAA) provides standards for protecting patients’ medical records and other personal health information. 39 HIPAA also requires safeguards to be put in place to protect personal health information privacy, and to set limits and conditions on its use and disclosure without patient authorization. 39 While there is a duty to protect all patients’ privacy, it can be more challenging for those with V.I.P. status, such as celebrities, who may be at greater risk for privacy breach. 9 For example, the media may attempt to access their protected health information, and healthcare professionals can be tempted to violate privacy policies and legal norms to access a celebrity’s records. As such, some V.I.P. patients may require greater resources to achieve the same level of protection as the general population. However, this does not include reducing the privacy of the general patient population or depriving them of needed resources. There are documented instances where celebrities’ health information privacy was breached by hospital employees, and shared with tabloids. This is, therefore, one instance where it may be ethically justifiable to take special measures to ensure the privacy of at risk V.I.P. patients to provide care that is equivalent to other patients without harming the privacy of the general patient population.
Ethical obligations and recommendations
This article seeks to advocate for care equity among all patients, contrary to Weintraub’s 2 recommendation for hospitals to be prepared to show V.I.P. patients special considerations, and Feuer and Karasu 20 guidance for staff development to ensure that staff are able to anticipate and effectively deal with issues of caring for V.I.P. or “special patients.” All patients are entitled to receive quality, safe, and efficient care. When resources are drained by the delivery of special care to V.I.P. patients, it is unethical. Solutions to mitigate this issue could include the addition of extra staff, administrators refraining from pressuring staff to treat V.I.P. patients differently, and a general organizational culture that respects and values all human beings.
As the largest group of healthcare professionals, nurses are in the position to assume ownership of the elimination of the disparities and inequities imposed by the V.I.P. care practices. In the United Kingdom, the Code for Nurses calls for the reputation of the profession to be upheld at all times, including treating people fairly without any discrimination, and acting as an advocate for the vulnerable, challenging poor practice, and discriminatory attitudes and behavior relating to their care.
40
The Australian Code of Ethics for Nurses places emphasis on the provision of non-harmful, non-discriminatory nursing care that is appropriate to the individual recognizing their particular needs and rights, seeking to “eliminate prejudicial attitudes concerning personal characteristics such as race, ethnicity, culture, gender, sexuality, religion, spirituality, disability, age and economic, social or health status” even when care is extended to members of the nurse’s family, their partners, friends, and other members of a person’s nominated social network.
41
In the United States, the Code of Ethics for Nurses with Interpretive Statements provides a guide for nurses to use in ethical analysis and decision making… It is foundational to nursing theory, practice, and praxis in its expression of the values, virtues, and obligations that shape, guide, and inform nursing as a profession (p. vii).
36
The ANA calls on nurses to be alert and take action in all instances where unethical, inappropriate, or questionable practice put the rights of patients in jeopardy. V.I.P. care can violate patient rights, and places all patients safety in jeopardy. While nurses may experience powerlessness and fear for the safety of their employment, advocating for care equity is imperative. This may include escalation to managers or administrators, and in some cases external authority. 36
The ANA 36 further adds that “nurses have vested authority, and are accountable and responsible for the quality of their practice” (p. 15). Nurses may be placed in situations where their integrity may be threatened by being asked to take actions that can deceive patients and are inconsistent with the ANA Code of Ethics for Nurses. When nurses are faced with the ethical dilemma of providing V.I.P. care that jeopardizes the care of others, they can express their “conscientious objection” which the ANA 36 defines as “a conscience-based refusal, on moral or religious grounds, to act or participate in an action that falls within the scope of one’s practice” (p. 42). When V.I.P. care compromises the care of others, it can threaten the integrity of individual nurses and that of the nursing profession, it can deceive the patients who entrust their lives in the care of nurses, and it can be inconsistent with the ANA Code of Ethics for Nurses. Therefore, expressing “conscientious objection” to providing V.I.P. care is an ethical responsibility of every nurse. As Immanuel Kant suggested “Act in such a way that you treat humanity, whether in your own person or in the person of another, always at the same time as an end and never simply as a means.” 42
According to the ANA, a morally good environment fosters communication, respect, transparency, and moral equality. 36 Nurse administrators have the responsibility and accountability to ensure an ethical environment that fosters safe and quality care for all patients. Therefore, demanding V.I.P. care, when there is no justifiable reason can violate this provision, and compromise patient safety.
All patients are “very important.” V.I.P. care can lead to challenges and ethical dilemmas for nurses. The Institute of Medicine (IOM) urged that it is unacceptable for patients to be harmed by the healthcare system that promises to “first, do no harm”; it further stated that Americans should anticipate receiving care to meet their needs that is based on the best scientific knowledge. 43 V.I.P. care does not meet the Institute for Medicine recommendations for healthcare transformation, particularly that of providing equitable care which it defines as “care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status” (pp. 5, 6). 43
Conclusion
Although V.I.P. care is reflected in the medical literature, and has been integrated in healthcare delivery, it has remained a quiet reality in nursing with very limited attention. Patients identified as V.I.P. can require special care and attention. At times, the special care can lead to under- or over-utilization of healthcare resources. V.I.P. care has been found to lead to negative outcomes for both patients in that category and the general patient population. Despite this, hospital administrators continue to support the practice of providing care that is tailored to V.I.P. patients that is not always solely based on medical needs.
Depleting already scarce nursing resources to provide special care to V.I.P. patients is unethical. Placing the safety of V.I.P. and non-V.I.P. patients at risk in order to accommodate V.I.P. requests or to succumb to external pressures to provide special treatment is unethical. While some aspects of V.I.P. care, such as the provision of heightened privacy for well-known celebrities, may be justifiable, V.I.P. care can violate the bioethical principles of nonmaleficence, beneficence, and distributive justice. V.I.P. care can cause suffering to patients and staff, and can contribute to nursing care rationing practices As Peirce proposed, the essence of nursing care is to protect patients from harm by anticipating, preventing, reducing, and removing harm from patients. 44
To manage the ethical dilemmas that can arise from V.I.P. care, this article recommends the integration of bioethical principles and the ANA Code of Ethics for Nurses. In addition, understanding the implications of caring for patients categorized as V.I.P., such as the risks for harm to both V.I.P. and non-V.I.P. patients, and some of its advantages is paramount. Special V.I.P. consideration can be justified for important societal leaders, such as a country’s president, whose welfare can be essential and crucial to the common good of society. This, however, cannot be accomplished by sacrificing the quality of care and the safety of other patients. V.I.P. care provided on special-priced luxuriously designed units to meet the needs of this group is justifiable when it does not interfere with the care of the general patient population. Finally, V.I.P. care provided in private service sectors where individuals have the option to pay for special V.I.P. care is also justifiable. While this article focuses primarily on the United States healthcare system, it also bears implications for other systems where nurses may face similar challenges in the delivery of V.I.P. care. In two studies of nurses from Iran and Ghana, for example, the challenges of V.I.P. care and care disparities between private and public inpatient hospitals emerged. 29,32
Healthcare organizations should have protocols and procedures in place that apply to all patients which should only be altered after cautious review and consideration for potential moral and ethical issues. The ANA 36 states that “The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy” (p. 35). As such, the practice of V.I.P. care is one that needs to be on the agendas of professional nursing organizations and health policy. It can also be beneficial to consider adding new provisions about V.I.P. care in nursing ethical codes which can empower and prepare nurses for the ethical dilemmas of V.I.P. care delivery. In summary, V.I.P. care presents many challenges, opportunities, and potential dangers. Therefore, it is important for nurses, as the largest group of healthcare professionals, to acknowledge these challenges as they are the most affected by V.I.P. care.
Footnotes
Acknowledgements
The author would like to thank Dr. Anne Peirce of Adelphi University College of Nursing and Public Health for her support, and guidance in providing feedback on multiple iterations of this article.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
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