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Ethics and Managed Care: Reconstructing a System and Refashioning a Society

Ethics and Managed Care: Reconstructing a System and Refashioning a Society IN THIS issue of the ARCHIVES, Kuczewski and DeVita1 present and analyze a case typical of today's managed care environment. It is a complex case that has a number of troubling ethical aspects, as in many ways does their conclusion. In this editorial, I will briefly examine some of the issues that this very troubling case raises. Crafting a method to deal with these issues will inevitably shape how technical medicine is practiced and will also critically affect how ethical problems of medical practice are understood and addressed. The situation presented in the article by Kuczewski and DeVita—one in which a patient whom, for reasons of cost, the hospital is anxious to transfer to another and lesser facility, a facility that at least the family and possibly the physicians and nurses feel has a less-than-optimal level of care—is not new to medical practice. Patients or their families have often been reluctant to follow the recommendations of health care professionals to leave one institution to go either home or to another facility. Likewise, physicians have been forced by circumstances to transfer patients before maximal or optimal benefit has been attained. Such transfers have not always been purely patient-centered. Sometimes they have been made because of a shortage of beds; sometimes there have been other considerations. What is different now is that the pressures to transfer brought to bear on the patient, family, and health care team are much greater than in years past, and the financial and professional consequences for everyone involved are more dire. Patient and family are threatened with loss of insurance benefits (and with ultimate pauperization); physicians and other members of the health care team are coerced by threats to their careers and livelihoods ranging from disfavor with the powers that be (which in today's environment are far more blatantly those who hold the purse strings) to financial penalties and even loss of professional position. In the background lurks the administration of not only the hospital but also the insurer, and behind the administration lurk the "owners" of the insurer or managed care organization (in the case of for-profit managed care, the stockholders; and in both for-profit and not-for-profit organizations, the Chief Executive Officer and his or her staff) interested in saving as much money as possible. Since it is the physician who must write the order for transfer or discharge, it is ultimately the physician who is morally and legally responsible for the patient's well-being; and it is the patient and the patient's family who are forced to bear the consequences that range from less-than-optimal care to financial ruin. The managers and owners escape all responsibility; they are, after all, not practicing medicine. But even if, as one can hope and as seems likely, the Employee Retirement Income Security Act of 1974 loophole that allows managed care organizations to escape proper responsibility is closed, the undue coercion and ultimate risk for the physician remains—and so, above all, does the ethical quandary.2 (The day when managed care organizations can claim legal immunity may be ending. Until recently, managed care organizations [availing themselves of an Employee Retirement Income Security Act loophole] could not be sued. Recent laws enacted by Texas3 may close this loophole in Texas and, depending on the outcome of a court challenge, serve as a model for other states.) Kuczewski and DeVita suggest that full disclosure to the patient and family of their insurance status would address the ethical problem. Full disclosure of the risks and benefits of medical therapy certainly go a long way toward addressing many of the problems of patient consent in medical practice, so why not provide full disclosure of the financial as well as medical risks? In what is to follow, I shall maintain that while full disclosure of all reasonable and relevant factors is ethically appropriate to allow a patient to make an informed decision, full disclosure alone fails to address the ethical problem. When patients are given a choice of therapies (and, of course, the alternative of no therapy) they may feel coerced. No psychologically healthy person, for example, actually desires to have surgery or to swallow unpleasant medications unless he or she perceives the alternative to be considerably worse. They are, as it were, coerced—by the thought of their illness and its prognosis if left untreated—into choosing something that they would not ordinarily want to do. Their illness, however, is a natural state—one imposed on them not by artificial circumstance but as a result of what has been called the "natural lottery."4 (The term "natural lottery" in health care ethics has been used to justify the denial of communal responsibility for health care.5) Lung cancer and other illnesses may, in part, be self-induced, but lung cancer and other illnesses, once they exist, are not imposed on patients directly by a social structure over which they have little say. Thus, full disclosure of all relevant aspects of the health system is essential if patients are to be able to choose wisely from an array of choices and optimize their health care value. When full disclosure of insurance "benefits" (why do we call something a benefit when it can be used to coerce people to do what they least want to do?) is made, patients and families are then allegedly "free" to choose; the choice, however, is often between financial ruin and a type of care that not only fails to optimize their health care value but may, in fact, destroy them. Full disclosure alone does not provide the patient optimal health care value. Physicians and other members of the health care team see their mission as treating the symptoms and illnesses presented by their patients. They do not see their mission (and society does not see their mission) as acting as fiscal officers. In our current managed care environment, the role of physicians and other health care workers has been distorted. Health care professionals (and especially physicians) are now placed in the role of having to simultaneously act as the patients' advocates and conservators of managed care resources. Often, if not invariably, this presents a blatant conflict of interests; and today another player is often involved: the ethics consultant or ethics committee, who must operate in an environment where the major responsible players (patient, family, and health care team) who must deal with the consequences are disempowered. Power resides and acts (and is legally shielded) behind the scenes. For this reason, full disclosure might be helpful—but it would be helpful not so much in resolving the individual conflict as in bringing pressure to change an intolerable system or, at the very least, to reveal the system to those involved and allow them to decide if such a system should be legally protected or, in fact, tolerated. Resources in any system of health care must be conserved—they are not limitless, and this ultimately means some sort of rationing. However, although we all too often think of resources as merely monetary, they also include (perhaps more importantly) time, devotion, patience, and energy, as well as material things (such as the last bed in the intensive care unit or a heart to be transplanted) that are not measurable merely in monetary terms. These resources too are precious (at least as precious as money and, in a sense, even less renewable), and these too need to be rationed. When physicians and other members of the health care team are placed in positions in which they must bear the primary medical responsibility for their actions while being forced to act at the direction of a third, nonmedical party, another resource—loyalty to one's responsibilities—is threatened: the burnout rate among health care professionals is high today.6 (Although the burnout rate among physicians today, and especially those working in managed care settings, has been widely noted and is not only the subject of much discussion but even of some continuing medical education courses, it is unfortunate that few papers actually giving facts and figures appear in the literature.) As health care professionals, we can see ourselves in 1 of 3 basic ways: (1) as individuals working within a health care system over which we have no control, making individual ethical choices to comply with or circumvent the situation; the former is blind obedience, the latter (also called "gaming the system") is disingenuous; (2) as members of a group, who, by acting in solidarity, can actually shape the health care system and therefore determine the context within which ethical problems present themselves; or (3) as a combination of both: as individual practitioners who must do the best we can within the context of a given situation but who are fully aware and ready to act together to bring about constructive change; who can, while working within the system, realize that we can improve the system. Care has always been managed—medical student education, peer review procedures, and continuing medical education all ultimately "manage" care to assure a proper technical quality of diagnosis and treatment.7 It is not possible today to keep financial concerns entirely separate. Care managed to assure equitable access and good quality to all members of a community (be that a community of insured or, as I would see it, a larger community) is quite a different thing from care managed to achieve the lowest costs possible while avoiding lawsuits. Whether one is a lone practitioner or a managed care organization, fear of malpractice suits must not be the sole motivation to provide good care. There are 3 ways of organizing managed care: (1) to increase profits of a managed care organization, its stockholders, and executives (resources conserved to financially benefit persons not directly concerned with health care delivery); (2) to provide care through a not-for-profit organization to the members of a given insured community (resources conserved, at least in theory, to deliver the best care possible to a group insured within a particular system); or (3) to provide care to a broader community. When a community (state, society, nation) undertakes health system management, it does so to provide equitable access (or at least basic access) to all members of the community as well as to balance what is spent for health care with other values deemed important by the community. In communities, there are no stockholders, and basic decisions can be made democratically (given the proper social and political system) by the members of the community who are ultimately affected. In other words, a community health care organization would be similar to an all-encompassing not-for-profit managed care organization in which decisions as to allocation would be made by all affected. To be successful, such an organization must allow sufficient discretion to health care professionals. The particulars of such an arrangement would have to be worked out in communal dialogue with the advice and consent of health care professionals (and the advice of other experts), and it must be worked out in a democratic fashion. All who may ultimately be affected must have the opportunity to speak, and all must realize that they will have to abide by the decisions they have participated in making. One cannot practice truly ethically within the context of an unethical or corrupt health care system. The system conditions and sometimes determines the options one has and the choices one will make. Today's managed care environment has made ethical practice most difficult—the case under discussion is a case in point and demonstrates one of many problems. Managed care as we know it has badly distorted the physician-patient relationship in many ways. It has limited the time of actual physician-patient contact and thus inhibited the dialogue between health care providers and patients. It has created an atmosphere of suspicion in which patients and perhaps also health care professionals are justifiably uncertain about the motives prompting physicians to make a given decision. Informing patients of their insurance status is certainly part of "informing," albeit yet another nonmedical obligation health care professionals might be saddled with. However, while it may be the best one can do in today's managed care environment to inform patients that they are not covered by insurance in the hospital and that they have the choice between leaving to receive inferior care elsewhere, on the one hand, or staying and being financially ruined on the other, this does not exhaust (or even begin to describe) the obligations physicians have to patients. If health care professionals are truly convinced that patients no longer require hospitalization, that they have reached what was once routinely called "MHB"—maximal hospital benefit—on discharge, that is as it should be; but when health care professionals are fully aware that benefits are far from "maximal" or "optimal" and nevertheless discharge the patient, they no longer meet the obligation of acting in the patient's best medical interest. When hospital or managed care administration demands that such patients be discharged, let the administration and not the health care professionals so discharge the patient, and let the administration and not health care professionals bear the full moral and legal responsibility for doing so. I certainly do not argue that the kind of private, fee-for-service system that was the rule some years ago has much more than today's system of managed care to recommend it. These alternatives, however (private, fee-for-service medicine or for-profit, non–community-based managed care), hardly exhaust the range of possible health systems. If physicians are truly troubled, as they ought to be, by the ethical problems of managed care, then they must do more than simply adapt themselves to such a system and "do the best they can" within it; they must play their part in changing what they perceive to be a system hostile to their own, their patient's, and the community's conception of ethical practice. They must, in fact, actively and with the means they have at hand work to change the system itself. Beyond this, and because it is difficult to establish a just system within the context of an unjust society, physicians should attempt to play at least a modest part in affecting societal changes. I am neither Pollyanna nor defeatist about this—a perfectly ethical system and a perfectly just society are things we can strive for but perhaps not things we can achieve completely in the real world. However, that does not absolve us of the responsibility to try: just because we cannot fully heal a patient does not eliminate our obligation to try to improve the patient's condition; just because we cannot create a perfect system does not eliminate our obligation to try to create a more satisfactory system and a more acceptable society. I am not suggesting that physicians take to the barricades or devote their lives to social action, although some might well do so. Nor am I suggesting that physicians are social engineers who have the obligation to bring about social change. Medicalizing social problems carries with it grave risks. But I do argue that as citizens and as medical experts, physicians have a responsibility to try to bring about constructive change in the health care system as well as in society. The fact that 32 million persons in this country are, except in a life-threatening emergency or as recipients of capricious charity, without access to medical care and that many more are underinsured cannot (or at least if physicians are to act in a socially and ethically responsible manner as citizens and as professionals, ought not) leave physicians unconcerned. The fact that many children as well as adults today are hungry, homeless, and forced to live below what is considered to be the poverty line and the fact that these social conditions adversely and severely affect the health of individuals and ultimately of the community likewise cannot (or at least if physicians are to act in a socially and ethically responsible manner as citizens and as professionals, ought not) leave physicians unconcerned. Effecting meaningful change in a system or in a society requires those seeking change to act in concert. If democracy is to mean anything at all, it must mean that a majority of persons in that democracy acting together can bring about effective change. Any deviation from this (to paraphrase Abraham Lincoln) to the extent of that deviation is no longer democracy. Why have we, as a society and a profession, failed, and why do we continue to fail? Many have remarked on the individualism that pervades this culture. It is an individualism that, when understood in the context of communal needs, has enabled personal freedom and opportunity. That is its positive side. Unfortunately, emphasis on individual freedom within the context of community has given way to what Jonathan Moreno8 has aptly termed the "myth of the asocial individual"—a myth destructive not only of community but ultimately also of personal freedom.9 This myth and the way it has played itself out is inimical to the democratic process, which squarely rests on the conception of a vigorous, interactive, and communicative community. Physicians lamenting the fact that their ethical options are seriously limited by today's managed care atmosphere generally feel that there is nothing they can do. And if they subscribe to the myth of the asocial individual, if they see themselves as isolated moral agents powerless by themselves to change a course of events dictated by powerful forces, they are quite correct. "There is nothing I can do" is, within limits, true enough when the "I" refers to single persons acting alone; it is quite wrong when the "I" is a collective one and refers to a group in which solidarity permits communal action. Physicians do not have to sit still and see their moral options severely narrowed; citizens likewise do not have to sit still and watch their social opportunities vanish. Both can act together, realize their interrelationship and their interdependence, and work in concert to effect change. Solidarity and collective action are the very essence of democratic change. As long as medical professionals and the public allow themselves to be exploited by organizations out to maximize their own profit, no constructive change will ever occur. Changing the managed care environment, however, makes sense only if a viable alternative to such a system can be offered. A return to a pure and untrammeled fee-for-service health care system in which no controls of what can be offered exist is, in today's society, hardly a viable option. It is not a viable option because it means that the costs of medical care will continue to escalate until an even greater number of persons will be uninsured, underinsured, and uncared for. The creation of a system of care in which the managing is done at a communal level to maximize equity and minimize waste is not beyond our capacity. The basis of what I have suggested is a rededication to the democratic process within both the profession and society. There have been some feeble attempts in this direction, among which is the method for initiating what has come to be called the Oregon plan. The democratic process, however, comprises more than merely political democracy—honest elections in which the ballot boxes are not stuffed, in which outright bribes are not given, and in which voting districts are not grossly gerrymandered does not exhaust the idea of democracy. The idea of democracy (based on the value and power of the community) and the idea of the "asocial individual" (based on stark individualism) make strange and ultimately incompatible bedfellows. A viable political democracy (as John Dewey pointed out long ago) rests squarely on the shoulders of at least 3 preconditions: personal democracy in which all of us are willing to engage in respectful dialogue with one another; economic (Dewey calls it "industrial") democracy in which all are assured the basic necessities of life; and educational democracy in which educational opportunities are freely available for all to pursue their interests and develop their talents.10,11 Absent these 3 preconditions, political democracy is not only liable but likely to become the plaything of powerful interest groups. Political democracy is then reduced to a circus in which serious affairs of state become games, genuine options disappear, and our destiny is wrested from our hands. Increasingly, both the microcosm of managed care and the macrocosm of our society serve as prime examples of this degraded form of democracy. The problems of managed care (ethical as well as others) have given us a wonderful opportunity to get serious about reconstructing not only our health system but with it our society. Giving equitable access to health care to all within our borders will be a step toward creating a society more just, more free, more interactive, and more successful than our present one. Health care professionals can and should lead the way. References 1. Kuczewski MGDeVita M Managed care and end-of-life decisions: learning to live ungagged. Arch Intern Med. 1998;1582424- 2428Google ScholarCrossref 2. Tottenham TOWilson RFJewell CM Leveling the playing field? the nation's first managed care liability law. J Health Hosp Law. 1998;3114- 22Google Scholar 3. Not Available, Not Available Tex statute S 386, 75th Leg 1997, Reg Sess, Tex Senate 1997;Google Scholar 4. Rawls J A Theory of Justice. Cambridge, Mass Harvard University Press1971; 5. Engelhardt HT Health care allocations: response to the unjust, the unfortunate and the undesirable. Shelp EEed Justice and Health Care. Dordrecht, the Netherlands D. Reidel1981;121- 138Google Scholar 6. Deckard GMeterko MField D Physician burnout: an examination of personal, professional and organizational relationships. Med Care. 1994;32745- 754Google ScholarCrossref 7. Loewy EH Guidelines, managed care, and ethics. Arch Intern Med. 1996;1562038- 2040Google ScholarCrossref 8. Moreno J The social individual in clinical ethics. J Clin Ethics. 1992;353- 55Google Scholar 9. Loewy EH Moral Strangers, Moral Acquaintances and Moral Friends: Connectedness and Its Conditions. Albany, NY SUNY Publishers1997; 10. Dewey J Creative democracy: the task before us. Boydston JASharp Aeds John Dewey The Later Works, 1939-1941. Carbondale, Ill Southern Illinois University Press1991;224- 230Google Scholar 11. Dewey J The public and its problems. Boydston JAWalsh BAeds John Dewey The Later Works, 1925-1953. Carbondale, Ill Southern Illinois University Press1991;Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Ethics and Managed Care: Reconstructing a System and Refashioning a Society

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References (11)

Publisher
American Medical Association
Copyright
Copyright © 1998 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.158.22.2419
Publisher site
See Article on Publisher Site

Abstract

IN THIS issue of the ARCHIVES, Kuczewski and DeVita1 present and analyze a case typical of today's managed care environment. It is a complex case that has a number of troubling ethical aspects, as in many ways does their conclusion. In this editorial, I will briefly examine some of the issues that this very troubling case raises. Crafting a method to deal with these issues will inevitably shape how technical medicine is practiced and will also critically affect how ethical problems of medical practice are understood and addressed. The situation presented in the article by Kuczewski and DeVita—one in which a patient whom, for reasons of cost, the hospital is anxious to transfer to another and lesser facility, a facility that at least the family and possibly the physicians and nurses feel has a less-than-optimal level of care—is not new to medical practice. Patients or their families have often been reluctant to follow the recommendations of health care professionals to leave one institution to go either home or to another facility. Likewise, physicians have been forced by circumstances to transfer patients before maximal or optimal benefit has been attained. Such transfers have not always been purely patient-centered. Sometimes they have been made because of a shortage of beds; sometimes there have been other considerations. What is different now is that the pressures to transfer brought to bear on the patient, family, and health care team are much greater than in years past, and the financial and professional consequences for everyone involved are more dire. Patient and family are threatened with loss of insurance benefits (and with ultimate pauperization); physicians and other members of the health care team are coerced by threats to their careers and livelihoods ranging from disfavor with the powers that be (which in today's environment are far more blatantly those who hold the purse strings) to financial penalties and even loss of professional position. In the background lurks the administration of not only the hospital but also the insurer, and behind the administration lurk the "owners" of the insurer or managed care organization (in the case of for-profit managed care, the stockholders; and in both for-profit and not-for-profit organizations, the Chief Executive Officer and his or her staff) interested in saving as much money as possible. Since it is the physician who must write the order for transfer or discharge, it is ultimately the physician who is morally and legally responsible for the patient's well-being; and it is the patient and the patient's family who are forced to bear the consequences that range from less-than-optimal care to financial ruin. The managers and owners escape all responsibility; they are, after all, not practicing medicine. But even if, as one can hope and as seems likely, the Employee Retirement Income Security Act of 1974 loophole that allows managed care organizations to escape proper responsibility is closed, the undue coercion and ultimate risk for the physician remains—and so, above all, does the ethical quandary.2 (The day when managed care organizations can claim legal immunity may be ending. Until recently, managed care organizations [availing themselves of an Employee Retirement Income Security Act loophole] could not be sued. Recent laws enacted by Texas3 may close this loophole in Texas and, depending on the outcome of a court challenge, serve as a model for other states.) Kuczewski and DeVita suggest that full disclosure to the patient and family of their insurance status would address the ethical problem. Full disclosure of the risks and benefits of medical therapy certainly go a long way toward addressing many of the problems of patient consent in medical practice, so why not provide full disclosure of the financial as well as medical risks? In what is to follow, I shall maintain that while full disclosure of all reasonable and relevant factors is ethically appropriate to allow a patient to make an informed decision, full disclosure alone fails to address the ethical problem. When patients are given a choice of therapies (and, of course, the alternative of no therapy) they may feel coerced. No psychologically healthy person, for example, actually desires to have surgery or to swallow unpleasant medications unless he or she perceives the alternative to be considerably worse. They are, as it were, coerced—by the thought of their illness and its prognosis if left untreated—into choosing something that they would not ordinarily want to do. Their illness, however, is a natural state—one imposed on them not by artificial circumstance but as a result of what has been called the "natural lottery."4 (The term "natural lottery" in health care ethics has been used to justify the denial of communal responsibility for health care.5) Lung cancer and other illnesses may, in part, be self-induced, but lung cancer and other illnesses, once they exist, are not imposed on patients directly by a social structure over which they have little say. Thus, full disclosure of all relevant aspects of the health system is essential if patients are to be able to choose wisely from an array of choices and optimize their health care value. When full disclosure of insurance "benefits" (why do we call something a benefit when it can be used to coerce people to do what they least want to do?) is made, patients and families are then allegedly "free" to choose; the choice, however, is often between financial ruin and a type of care that not only fails to optimize their health care value but may, in fact, destroy them. Full disclosure alone does not provide the patient optimal health care value. Physicians and other members of the health care team see their mission as treating the symptoms and illnesses presented by their patients. They do not see their mission (and society does not see their mission) as acting as fiscal officers. In our current managed care environment, the role of physicians and other health care workers has been distorted. Health care professionals (and especially physicians) are now placed in the role of having to simultaneously act as the patients' advocates and conservators of managed care resources. Often, if not invariably, this presents a blatant conflict of interests; and today another player is often involved: the ethics consultant or ethics committee, who must operate in an environment where the major responsible players (patient, family, and health care team) who must deal with the consequences are disempowered. Power resides and acts (and is legally shielded) behind the scenes. For this reason, full disclosure might be helpful—but it would be helpful not so much in resolving the individual conflict as in bringing pressure to change an intolerable system or, at the very least, to reveal the system to those involved and allow them to decide if such a system should be legally protected or, in fact, tolerated. Resources in any system of health care must be conserved—they are not limitless, and this ultimately means some sort of rationing. However, although we all too often think of resources as merely monetary, they also include (perhaps more importantly) time, devotion, patience, and energy, as well as material things (such as the last bed in the intensive care unit or a heart to be transplanted) that are not measurable merely in monetary terms. These resources too are precious (at least as precious as money and, in a sense, even less renewable), and these too need to be rationed. When physicians and other members of the health care team are placed in positions in which they must bear the primary medical responsibility for their actions while being forced to act at the direction of a third, nonmedical party, another resource—loyalty to one's responsibilities—is threatened: the burnout rate among health care professionals is high today.6 (Although the burnout rate among physicians today, and especially those working in managed care settings, has been widely noted and is not only the subject of much discussion but even of some continuing medical education courses, it is unfortunate that few papers actually giving facts and figures appear in the literature.) As health care professionals, we can see ourselves in 1 of 3 basic ways: (1) as individuals working within a health care system over which we have no control, making individual ethical choices to comply with or circumvent the situation; the former is blind obedience, the latter (also called "gaming the system") is disingenuous; (2) as members of a group, who, by acting in solidarity, can actually shape the health care system and therefore determine the context within which ethical problems present themselves; or (3) as a combination of both: as individual practitioners who must do the best we can within the context of a given situation but who are fully aware and ready to act together to bring about constructive change; who can, while working within the system, realize that we can improve the system. Care has always been managed—medical student education, peer review procedures, and continuing medical education all ultimately "manage" care to assure a proper technical quality of diagnosis and treatment.7 It is not possible today to keep financial concerns entirely separate. Care managed to assure equitable access and good quality to all members of a community (be that a community of insured or, as I would see it, a larger community) is quite a different thing from care managed to achieve the lowest costs possible while avoiding lawsuits. Whether one is a lone practitioner or a managed care organization, fear of malpractice suits must not be the sole motivation to provide good care. There are 3 ways of organizing managed care: (1) to increase profits of a managed care organization, its stockholders, and executives (resources conserved to financially benefit persons not directly concerned with health care delivery); (2) to provide care through a not-for-profit organization to the members of a given insured community (resources conserved, at least in theory, to deliver the best care possible to a group insured within a particular system); or (3) to provide care to a broader community. When a community (state, society, nation) undertakes health system management, it does so to provide equitable access (or at least basic access) to all members of the community as well as to balance what is spent for health care with other values deemed important by the community. In communities, there are no stockholders, and basic decisions can be made democratically (given the proper social and political system) by the members of the community who are ultimately affected. In other words, a community health care organization would be similar to an all-encompassing not-for-profit managed care organization in which decisions as to allocation would be made by all affected. To be successful, such an organization must allow sufficient discretion to health care professionals. The particulars of such an arrangement would have to be worked out in communal dialogue with the advice and consent of health care professionals (and the advice of other experts), and it must be worked out in a democratic fashion. All who may ultimately be affected must have the opportunity to speak, and all must realize that they will have to abide by the decisions they have participated in making. One cannot practice truly ethically within the context of an unethical or corrupt health care system. The system conditions and sometimes determines the options one has and the choices one will make. Today's managed care environment has made ethical practice most difficult—the case under discussion is a case in point and demonstrates one of many problems. Managed care as we know it has badly distorted the physician-patient relationship in many ways. It has limited the time of actual physician-patient contact and thus inhibited the dialogue between health care providers and patients. It has created an atmosphere of suspicion in which patients and perhaps also health care professionals are justifiably uncertain about the motives prompting physicians to make a given decision. Informing patients of their insurance status is certainly part of "informing," albeit yet another nonmedical obligation health care professionals might be saddled with. However, while it may be the best one can do in today's managed care environment to inform patients that they are not covered by insurance in the hospital and that they have the choice between leaving to receive inferior care elsewhere, on the one hand, or staying and being financially ruined on the other, this does not exhaust (or even begin to describe) the obligations physicians have to patients. If health care professionals are truly convinced that patients no longer require hospitalization, that they have reached what was once routinely called "MHB"—maximal hospital benefit—on discharge, that is as it should be; but when health care professionals are fully aware that benefits are far from "maximal" or "optimal" and nevertheless discharge the patient, they no longer meet the obligation of acting in the patient's best medical interest. When hospital or managed care administration demands that such patients be discharged, let the administration and not the health care professionals so discharge the patient, and let the administration and not health care professionals bear the full moral and legal responsibility for doing so. I certainly do not argue that the kind of private, fee-for-service system that was the rule some years ago has much more than today's system of managed care to recommend it. These alternatives, however (private, fee-for-service medicine or for-profit, non–community-based managed care), hardly exhaust the range of possible health systems. If physicians are truly troubled, as they ought to be, by the ethical problems of managed care, then they must do more than simply adapt themselves to such a system and "do the best they can" within it; they must play their part in changing what they perceive to be a system hostile to their own, their patient's, and the community's conception of ethical practice. They must, in fact, actively and with the means they have at hand work to change the system itself. Beyond this, and because it is difficult to establish a just system within the context of an unjust society, physicians should attempt to play at least a modest part in affecting societal changes. I am neither Pollyanna nor defeatist about this—a perfectly ethical system and a perfectly just society are things we can strive for but perhaps not things we can achieve completely in the real world. However, that does not absolve us of the responsibility to try: just because we cannot fully heal a patient does not eliminate our obligation to try to improve the patient's condition; just because we cannot create a perfect system does not eliminate our obligation to try to create a more satisfactory system and a more acceptable society. I am not suggesting that physicians take to the barricades or devote their lives to social action, although some might well do so. Nor am I suggesting that physicians are social engineers who have the obligation to bring about social change. Medicalizing social problems carries with it grave risks. But I do argue that as citizens and as medical experts, physicians have a responsibility to try to bring about constructive change in the health care system as well as in society. The fact that 32 million persons in this country are, except in a life-threatening emergency or as recipients of capricious charity, without access to medical care and that many more are underinsured cannot (or at least if physicians are to act in a socially and ethically responsible manner as citizens and as professionals, ought not) leave physicians unconcerned. The fact that many children as well as adults today are hungry, homeless, and forced to live below what is considered to be the poverty line and the fact that these social conditions adversely and severely affect the health of individuals and ultimately of the community likewise cannot (or at least if physicians are to act in a socially and ethically responsible manner as citizens and as professionals, ought not) leave physicians unconcerned. Effecting meaningful change in a system or in a society requires those seeking change to act in concert. If democracy is to mean anything at all, it must mean that a majority of persons in that democracy acting together can bring about effective change. Any deviation from this (to paraphrase Abraham Lincoln) to the extent of that deviation is no longer democracy. Why have we, as a society and a profession, failed, and why do we continue to fail? Many have remarked on the individualism that pervades this culture. It is an individualism that, when understood in the context of communal needs, has enabled personal freedom and opportunity. That is its positive side. Unfortunately, emphasis on individual freedom within the context of community has given way to what Jonathan Moreno8 has aptly termed the "myth of the asocial individual"—a myth destructive not only of community but ultimately also of personal freedom.9 This myth and the way it has played itself out is inimical to the democratic process, which squarely rests on the conception of a vigorous, interactive, and communicative community. Physicians lamenting the fact that their ethical options are seriously limited by today's managed care atmosphere generally feel that there is nothing they can do. And if they subscribe to the myth of the asocial individual, if they see themselves as isolated moral agents powerless by themselves to change a course of events dictated by powerful forces, they are quite correct. "There is nothing I can do" is, within limits, true enough when the "I" refers to single persons acting alone; it is quite wrong when the "I" is a collective one and refers to a group in which solidarity permits communal action. Physicians do not have to sit still and see their moral options severely narrowed; citizens likewise do not have to sit still and watch their social opportunities vanish. Both can act together, realize their interrelationship and their interdependence, and work in concert to effect change. Solidarity and collective action are the very essence of democratic change. As long as medical professionals and the public allow themselves to be exploited by organizations out to maximize their own profit, no constructive change will ever occur. Changing the managed care environment, however, makes sense only if a viable alternative to such a system can be offered. A return to a pure and untrammeled fee-for-service health care system in which no controls of what can be offered exist is, in today's society, hardly a viable option. It is not a viable option because it means that the costs of medical care will continue to escalate until an even greater number of persons will be uninsured, underinsured, and uncared for. The creation of a system of care in which the managing is done at a communal level to maximize equity and minimize waste is not beyond our capacity. The basis of what I have suggested is a rededication to the democratic process within both the profession and society. There have been some feeble attempts in this direction, among which is the method for initiating what has come to be called the Oregon plan. The democratic process, however, comprises more than merely political democracy—honest elections in which the ballot boxes are not stuffed, in which outright bribes are not given, and in which voting districts are not grossly gerrymandered does not exhaust the idea of democracy. The idea of democracy (based on the value and power of the community) and the idea of the "asocial individual" (based on stark individualism) make strange and ultimately incompatible bedfellows. A viable political democracy (as John Dewey pointed out long ago) rests squarely on the shoulders of at least 3 preconditions: personal democracy in which all of us are willing to engage in respectful dialogue with one another; economic (Dewey calls it "industrial") democracy in which all are assured the basic necessities of life; and educational democracy in which educational opportunities are freely available for all to pursue their interests and develop their talents.10,11 Absent these 3 preconditions, political democracy is not only liable but likely to become the plaything of powerful interest groups. Political democracy is then reduced to a circus in which serious affairs of state become games, genuine options disappear, and our destiny is wrested from our hands. Increasingly, both the microcosm of managed care and the macrocosm of our society serve as prime examples of this degraded form of democracy. The problems of managed care (ethical as well as others) have given us a wonderful opportunity to get serious about reconstructing not only our health system but with it our society. Giving equitable access to health care to all within our borders will be a step toward creating a society more just, more free, more interactive, and more successful than our present one. Health care professionals can and should lead the way. References 1. Kuczewski MGDeVita M Managed care and end-of-life decisions: learning to live ungagged. Arch Intern Med. 1998;1582424- 2428Google ScholarCrossref 2. Tottenham TOWilson RFJewell CM Leveling the playing field? the nation's first managed care liability law. J Health Hosp Law. 1998;3114- 22Google Scholar 3. Not Available, Not Available Tex statute S 386, 75th Leg 1997, Reg Sess, Tex Senate 1997;Google Scholar 4. Rawls J A Theory of Justice. Cambridge, Mass Harvard University Press1971; 5. Engelhardt HT Health care allocations: response to the unjust, the unfortunate and the undesirable. Shelp EEed Justice and Health Care. Dordrecht, the Netherlands D. Reidel1981;121- 138Google Scholar 6. Deckard GMeterko MField D Physician burnout: an examination of personal, professional and organizational relationships. Med Care. 1994;32745- 754Google ScholarCrossref 7. Loewy EH Guidelines, managed care, and ethics. Arch Intern Med. 1996;1562038- 2040Google ScholarCrossref 8. Moreno J The social individual in clinical ethics. J Clin Ethics. 1992;353- 55Google Scholar 9. Loewy EH Moral Strangers, Moral Acquaintances and Moral Friends: Connectedness and Its Conditions. Albany, NY SUNY Publishers1997; 10. Dewey J Creative democracy: the task before us. Boydston JASharp Aeds John Dewey The Later Works, 1939-1941. Carbondale, Ill Southern Illinois University Press1991;224- 230Google Scholar 11. Dewey J The public and its problems. Boydston JAWalsh BAeds John Dewey The Later Works, 1925-1953. Carbondale, Ill Southern Illinois University Press1991;Google Scholar

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Dec 7, 1998

Keywords: ethics,managed care programs

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