Managed care and ethical conflicts: Anything new?

Journal of Medical Ethics

Volumn 25, Issue 5, 1999, Pages 382-387

  Meyers, Christopher ^a  

^a NONE

Author keywords

Bias; Conflicts of interest; Managed care; Medical decision making; Obligation

Indexed keywords

DOCTOR PATIENT RELATION; HEALTH CARE FINANCING; HUMAN; MANAGED CARE; MEDICAL DECISION MAKING; MEDICAL ETHICS; MEDICAL PROFESSION; PHYSICIAN; REVIEW;

EID: 0032830664     PISSN: 03066800     EISSN: None     Source Type: Journal    
DOI: 10.1136/jme.25.5.382     Document Type: Review

References (61)

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2. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
3. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
4. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
5. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
6. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
7. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
8. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
9. Staab EV Consensus quest: reshaping the future of radiology. Radiology 1996;198,3:643-50; McDaniel C, Erlen J. Ethics and mental health service delivery under managed care. Issues in Mental Health Nursing 1996;17,1:11-20; Webb MS. Medical ethics under managed care: how can the patient survive? Annals of Plastic Surgery 1996;37,3:233-44; Chervenak FA, McCullough LB, Chez RA. Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology. American Journal of Obstetrics and Gynecology 1996;175,3 pt 1:523-7; Larkin GL, et al. Managed care ethics: an emergency? Annals of Emergency Medicine 1996;28,6:683-9; Basta L, Taught J. High technology near the end of life: setting limits [editorial]. Journal of the American College of Cardiology 1996;28,6:1623-30; Sunley R. Advocacy in the new world of managed care. Families in Society 1997;78,1:84-94; Backlar P. Managed mental health care: conflicts of interest in the provider/client relationship. Community Mental Health Journal 1996;32,2: 101-6; Foglio J, et al. What ethicists talk about when they talk about managed care. Hospital Health Network 1996;70,13: 24-5.
10. Swee DE. Health care system reform and the changing physician-patient relationship. New Jersey Medicine 1995;92,5: 313-7; Schwartz P. Medical ethics under managed care. International Journal of Fertility and Menopansal Studies 1996;41,2:124-8; Cassel CK. The patient-physician covenant: an affirmation of Asklepios. Connecticut Medicine 1996;60,5: 291-3; Warner EG. Ethics and morality vs managed care. Journal of the Oklahoma State Medical Association 1996;89,8: 75-9.
11. Swee DE. Health care system reform and the changing physician-patient relationship. New Jersey Medicine 1995;92,5: 313-7; Schwartz P. Medical ethics under managed care. International Journal of Fertility and Menopansal Studies 1996;41,2:124-8; Cassel CK. The patient-physician covenant: an affirmation of Asklepios. Connecticut Medicine 1996;60,5: 291-3; Warner EG. Ethics and morality vs managed care. Journal of the Oklahoma State Medical Association 1996;89,8: 75-9.
12. Swee DE. Health care system reform and the changing physician-patient relationship. New Jersey Medicine 1995;92,5: 313-7; Schwartz P. Medical ethics under managed care. International Journal of Fertility and Menopansal Studies 1996;41,2:124-8; Cassel CK. The patient-physician covenant: an affirmation of Asklepios. Connecticut Medicine 1996;60,5: 291-3; Warner EG. Ethics and morality vs managed care. Journal of the Oklahoma State Medical Association 1996;89,8: 75-9.
13. Swee DE. Health care system reform and the changing physician-patient relationship. New Jersey Medicine 1995;92,5: 313-7; Schwartz P. Medical ethics under managed care. International Journal of Fertility and Menopansal Studies 1996;41,2:124-8; Cassel CK. The patient-physician covenant: an affirmation of Asklepios. Connecticut Medicine 1996;60,5: 291-3; Warner EG. Ethics and morality vs managed care. Journal of the Oklahoma State Medical Association 1996;89,8: 75-9.
14. Warner EG. The current healthcare environment: who is the customer? Nursing Forum 1996;31,3:16-21; Erlen JA, Mellors M. Managed care and the nurse's obligations to patients. Orthopedic Nursing 1995;14,6:42-5.
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23. [Anonymous. Unattributed Associated Press story]. Doctors joining unions. The Bakersfield Californian 1997 Mar: A: 13, 15. As this article was being sent to press the 800 physicians who work for Los Angeles County, California, USA voted overwhelmingly to join the Union of American Physicians and Dentists. Riccardi N. LA County doctors vote decisively to unionize. Los Angeles Times 1999 May 29: A1, 22.
24. [Anonymous. Unattributed Associated Press story]. Doctors joining unions. The Bakersfield Californian 1997 Mar: A: 13, 15. As this article was being sent to press the 800 physicians who work for Los Angeles County, California, USA voted overwhelmingly to join the Union of American Physicians and Dentists. Riccardi N. LA County doctors vote decisively to unionize. Los Angeles Times 1999 May 29: A1, 22.
25. The term "managed care" is admittedly vague because it encompasses, in the United States at least, such a range of methods for altering the financing of health care services, including health maintenance organisations, independent physician associations and preferred provider associations. As Larry Churchill notes, however: "the common element is some strategy for delivering services in a more efficient way. Efficiency is achieved ... generally through measures that are geared to assure that only appropriate services are provided". Churchill LR. 'Damaged Humanity': The call for a patient-centered medical ethic in the managed care era. Theoretical Medicine 1997;18:118. The main concern for many physicians is that in the search for "efficiency" decisions are made for economic, not medical, reasons, and sometimes by accountants rather than trained medical personnel.
26. See reference 7: 119.
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28. Kipnis K. Conflict of interest and conflict of obligation. In: Davis M, Eliston FA, eds. Ethics and the legal profession. New York: Prometheus Books, 1986: 291.
29. See reference 10: 284.
30. That conflicts of interest are relatively easy to resolve does not mean that persons will in fact act accordingly, as evidenced by the plethora of such conflicts across all professions. Recognising one's moral obligation and having the strength of will to act upon it are obviously very different propositions.
31. See reference 2: Warner: 275.
32. See reference 2: Cassell: abstract.
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38. Gijsbers van Wijk CM, van Vliet KP, Kolk AM. Gender perspectives and quality of care: towards appropriate and adequate health care for women. Social Science and Medicine 1996;43,5:707-20; Fisher S. In the patient's best interest: women and the politics of medical decisions. New Brunswick, NJ: Rutgers University Press, 1986; Franks P, Clancy CM. Physician gender bias in clinical decisionmaking: screening for cancer in primary care. Medical Care 1993;31,3:213-8.
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48. Cross AW, Churchill LR. Ethical and cultural dimensions of informed consent. A case study and analysis. Annals of Internal Medicine 1982;96,1:110-3; Meyers C. The impact of physician denial on patient autonomy and wellbeing. Journal of Medical Ethics 1992;18,3: 135-7.
49. Since the time this paper was first submitted for review studies have been released which reveal that managed care may be having a greater negative impact on traditionally underserved populations, particularly non-white and poor, through the exclusion of "physicians who provide a greater share of charity care. Rather than rewarding these physicians for their socially responsible deeds, the health care marketplace seems to be excluding them," and, by consequence, their poor, non-white patients. Bindman AB, Grumbach K, Vranizan K, Jaffe D, Osmond D. Selection and exclusion of primary care physicians by managed care organizations. Journal of the American Medical Association 1998; 279,9:679. (Similar conclusions were drawn by Secundy M and Dula A in their respective panel presentations, Ethical issues in managed care. Association for Applied and Professional Ethics annual meeting, Dallas, Texas, USA, February 28, 1998.) While this is clearly a troubling consequence of managed care, it does not represent a new ethical dilemma. US health care has long struggled with adequately serving all segments of the population. It may be, as noted above, that the solution can only be found in a fundamental restructuring of the US system.
50. See reference 1: Backlar: 101-106.
51. Woolf SH. Practice guidelines: a new reality in medicine. III. Impact on patient care. Archives of Internal Medicine 1993; 153,23: 2646-55; Mechanic D. Physicians and patients in transition. Hastings Center Report 1985;15,6:9-12; Bellin LE. The shrinking autonomy of the practising physician and its impact on quality. Journal of Community Health 1986;11:155-64; Mirvis DM. Physicians' autonomy - the relation between public and professional expectations. New England Journal of Medicine 1993;328,18:1346-9; Nornhold P. Power: it's changing hands and moving your way. Nursing 1986;16:40-2; Daniels N. Understanding physician power: a review of the social transformation of American medicine. Philosophy and Public Affairs 1984;13:347-57, esp 353-7.
52. Woolf SH. Practice guidelines: a new reality in medicine. III. Impact on patient care. Archives of Internal Medicine 1993; 153,23: 2646-55; Mechanic D. Physicians and patients in transition. Hastings Center Report 1985;15,6:9-12; Bellin LE. The shrinking autonomy of the practising physician and its impact on quality. Journal of Community Health 1986;11:155-64; Mirvis DM. Physicians' autonomy - the relation between public and professional expectations. New England Journal of Medicine 1993;328,18:1346-9; Nornhold P. Power: it's changing hands and moving your way. Nursing 1986;16:40-2; Daniels N. Understanding physician power: a review of the social transformation of American medicine. Philosophy and Public Affairs 1984;13:347-57, esp 353-7.
53. Woolf SH. Practice guidelines: a new reality in medicine. III. Impact on patient care. Archives of Internal Medicine 1993; 153,23: 2646-55; Mechanic D. Physicians and patients in transition. Hastings Center Report 1985;15,6:9-12; Bellin LE. The shrinking autonomy of the practising physician and its impact on quality. Journal of Community Health 1986;11:155-64; Mirvis DM. Physicians' autonomy - the relation between public and professional expectations. New England Journal of Medicine 1993;328,18:1346-9; Nornhold P. Power: it's changing hands and moving your way. Nursing 1986;16:40-2; Daniels N. Understanding physician power: a review of the social transformation of American medicine. Philosophy and Public Affairs 1984;13:347-57, esp 353-7.
54. Woolf SH. Practice guidelines: a new reality in medicine. III. Impact on patient care. Archives of Internal Medicine 1993; 153,23: 2646-55; Mechanic D. Physicians and patients in transition. Hastings Center Report 1985;15,6:9-12; Bellin LE. The shrinking autonomy of the practising physician and its impact on quality. Journal of Community Health 1986;11:155-64; Mirvis DM. Physicians' autonomy - the relation between public and professional expectations. New England Journal of Medicine 1993;328,18:1346-9; Nornhold P. Power: it's changing hands and moving your way. Nursing 1986;16:40-2; Daniels N. Understanding physician power: a review of the social transformation of American medicine. Philosophy and Public Affairs 1984;13:347-57, esp 353-7.
55. Woolf SH. Practice guidelines: a new reality in medicine. III. Impact on patient care. Archives of Internal Medicine 1993; 153,23: 2646-55; Mechanic D. Physicians and patients in transition. Hastings Center Report 1985;15,6:9-12; Bellin LE. The shrinking autonomy of the practising physician and its impact on quality. Journal of Community Health 1986;11:155-64; Mirvis DM. Physicians' autonomy - the relation between public and professional expectations. New England Journal of Medicine 1993;328,18:1346-9; Nornhold P. Power: it's changing hands and moving your way. Nursing 1986;16:40-2; Daniels N. Understanding physician power: a review of the social transformation of American medicine. Philosophy and Public Affairs 1984;13:347-57, esp 353-7.
56. Woolf SH. Practice guidelines: a new reality in medicine. III. Impact on patient care. Archives of Internal Medicine 1993; 153,23: 2646-55; Mechanic D. Physicians and patients in transition. Hastings Center Report 1985;15,6:9-12; Bellin LE. The shrinking autonomy of the practising physician and its impact on quality. Journal of Community Health 1986;11:155-64; Mirvis DM. Physicians' autonomy - the relation between public and professional expectations. New England Journal of Medicine 1993;328,18:1346-9; Nornhold P. Power: it's changing hands and moving your way. Nursing 1986;16:40-2; Daniels N. Understanding physician power: a review of the social transformation of American medicine. Philosophy and Public Affairs 1984;13:347-57, esp 353-7.
57. "Some problems in the doctor-patient relationship currently exist [and] ... will exist regardless of the finance and delivery system (eg, the physician's ancient personal struggle between altruism and self-interest)". La Puma J. Anticipated changes in the doctor-patient relationship in the managed care and managed competition of the Health security Act of 1993. Archives of Family Medicine 1994; 3,8:665-71.
58. Ie, "Would I be particularly nervous should Mike Wallace (or some other reporter) show up at my office door to ask questions about this decision?" (Hulpke J. Personal communication, 1990. Professor Hulpke uses this test in his business ethics courses.)
59. This assumes, of course, the conscientious physician wishes to rid herself and her decisions of all bigotry - racial, ethnic, gender, sexual preference, etc.
60. Postema GJ. Moral responsibility in professional ethics. See reference 10: 171.
61. See reference 30: 161.