Ethics and hospital design

---

Many older hospital buildings reflect a mechanistic view of medicine, medical treatment and of patients. Their often labyrinthine collections of mechanical, electrical and structural systems and complex communication processes have been seen to express one of medicine’s modern metaphors – that the human body is a kind of machine composed of interrelated but independent and complex systems of tissue, blood, body organs and skeletons. A physically harsh environment of bright lights, hard floors, metallic equipment and loud sounds can amplify this mechanistic impression. One author described hospitals as places where “(H)ealing occurs in a kind of virtuous hell.” ⁱ

---

---

“The concept of the ‘fable hospital’ was introduced as a set of imagined ideal design features for health care institutions. ii These were presented as a business case to address the escalating costs of providing healthcare.”

---

About a decade ago, changes began to emerge in the ideas for the design of hospital buildings. The concept of the ‘fable hospital’ was introduced as a set of imagined ideal design features for health care institutions.ⁱⁱ These were presented as a business case to address the escalating costs of providing healthcare. The implementation has shown not only are the savings achieved but the fulfilment of central ethical obligations to patients is improved.
Perhaps the oldest and most well-known of those obligations is ‘do no harm’ – now rendered by the expression non-maleficence. Its corollary is the obligation to benefit patients – an obligation that became dominant as medicine increasingly proved its efficacy. In the recent decades since the 1960s, partly in response to an over dependence on those first two obligations and a sometimes unacceptable paternalism, the obligation to respect patients and particularly their decision-making and autonomy became as important, if not central, to contemporary discussions of ethics in health care
A brief description of some of the key features of new hospital design shows how they contribute to the fulfilment of these obligations.
The use of larger single rooms has improved patient outcomes by reducing hospital acquired infections, adverse drug events and falls. In addition they improve patient satisfaction, allow space for family members to visit and even stay overnight and increase their satisfaction with and involvement in the care of their family member. Larger windows with more natural light and natural views have been shown to improve patient recovery. Larger patient bathrooms with double door access assist staff and family members to assist patients moving to and from the bathroom.
The cumulative effect of these features of larger rooms more clearly expresses respect for patient choices and autonomy in the progress of their care.
A second feature is that of acuity adaptable rooms. These remove much of the need to move patients from one level of care acuity to another, a process shown to contribute to medical errors and patient harm. Reducing the necessity for such transfers reduces these errors, delays and patient risk. This appears to reflect a rejection of the mechanistic metaphor of modern medicine and to adopt a more patient-centred and holistic metaphor.
This shift in metaphors and its reflection in the use of acuity-adaptable rooms is a further expression of respect for patients and their autonomy. The consequences of reducing the risk of harm that transfers involved, whether from errors or patient movement, is a practical demonstration of the ethical obligation of non-maleficence.
A third feature has been noise reduction through the use of high performance sound absorbing ceiling tiles and finishes on walls and floors, carpeting where possible, noise and vibration isolated mechanical rooms, wireless pagers and reduced alarm sounds. All of these remove the stress and sleep deprivation of current noise levels that can delay recovery and in so doing, improve patients’ experience and recovery, better fulfilling the obligation of beneficence.
The use of family and social spaces benefit patients through family involvement in their care and health information resource centres provide readily available health information for patients to promote their self-care while in and following discharge from the hospital. Other implementations have emphasised nature and natural materials in the use of natural materials and colours in flooring and walls and the use of curved walls to soften the appearance of corridors and corners. These can benefit patients by improving their experience of and attitudes to hospital and their recovery.
Accordingly, these innovations in hospital design confirm the business case for more cost effective care and fulfil fundamental ethical obligations that hospitals and health professionals owed to their patients. Hospital design can be evidence based and ethically based.
Colin Thomson
BA, LLB, LLM (Sydney)
www.ehealthinfo.gov.au
Colin Thomson, BA, LLM (Sydney) is Professor of Law at the University of Wollongong and Academic Leader for Health Law and Ethics in the Graduate School of Medicine. He also works as a consultant.
He was a member of the Medical Research Ethics Committee (1988-91) of the National Health and Medical Research Council and, from 1998-2002 a member, and from 2006-2009, chair of the Australian Health Ethics Committee. As a consultant, he has advised NHMRC, FaHCSIA, Health Departments of NSW, Qld and Vic and several universities. He is a Senior Consultant with Australasian Human Research Ethics Consultancy Services (www.ahrecs.com).
Colin has provided training to human research ethics committees, chairs the CSIRO Social Science HREC and is a member of HRECs at Department of Health and Ageing and University of Wollongong/Illawarra Shoalhaven LHD.
He is a joint author of Good Medical Practice: professionalism, ethics and law, 2010, Cambridge University Press.

---

References
i Fisher, T. Architectural Design and Ethics, Routledge, 2008 p.122
ii Berry, L.L. et al The Business Case for Better Buildings, Frontiers Of Health Services Management, 2004 Fall; Vol. 21 (1), pp. 3-24