Managed care: an ethical reflection

Christian Century, August 12, 1998 by Edmund D. Pellegrino

THE MOST URGENTLY felt ethical conflict for the conscientious physician and nurse, secular or religious, is the erosion of the primacy of commitment to the welfare of the individual patient and person in a system of managed care. This primacy is compromised by the fact that health professionals in a managed care organization are employees. As such they receive compensation from the organization; de facto they owe allegiance to the organizational goals they are paid to pursue. These goals may or may not concur with the needs of their particular patients. These obligations to the organization can conflict with the duty of acting in the patient's best interests. This puts the physician inescapably in a position of double agency, which pits the patient's needs against those of the organization, the other patients in the same plan and the physician's own self-interest.

In a managed care system, emphasis shifts from the ethics of service to a particular patient to a population-based ethic. Physicians become responsible for taking into account the effect of their clinical decisions not just on the welfare of their patients but also on that of all the other patients enrolled in the system and even of society at large. This is to say nothing of the investors whose capital is at risk or of the physician's own legitimate self-interests.

Fee-for-service medicine, of course, also involves conflicts of interests and obligations. In the past, this conflict all too frequently resulted in unnecessary treatment. This is one of the reasons why managed care has been so avidly promoted by many. The major temptation in a fee-for-service system is that physicians earn more the more they do for their patients, even if the care is unnecessary. In managed care, the opposite is true: physicians are penalized if they do "too much"--that is, provide care not "covered" by the plan. Financial penalties or bonuses for productivity, cost savings or conservation of resources are deliberate manipulations of the physician's self-interest against the patient's. In a fee-for service system physicians are the identifiable miscreants. In managed care they share the blame. They share their acts of injustice with the organization that legitimates their actions. The other miscreants are the managed care administrator, the board of directors and the investors, all of whom are faceless and unknown to the patient.

Managed care that makes cost-containment or profit-taking as its end, at the expense of meeting legitimate needs of sick persons, threatens the most elementary notion of Christian ethics. It makes price, availability, accessibility and the quality of medical care a function of free-market determination or negotiation. It grants the doctor or the managed care organization a presumed proprietary right over medical knowledge. The justice of the business contract requires the physician or the organization to deliver nothing more than is owed by the conditions of the contract with the plan. If a patient at a young age opts unwisely for a cheaper plan with fewer or inappropriate benefits, that's just too bad.

Nor is it a concern of the managed care organization or the physician if patients do not have the wherewithal to become "players" in the market. No provision is made for those who have no insurance or inadequate insurance. Nor is there any solicitude for the many totally or partially illiterate members of American society who cannot understand an insurance plan, to say nothing of being able to choose one over another. Yet these people too become ill. They present themselves often as emergencies. No physician in good conscience can refuse to treat them even if no plan is willing to pay for the costs of their care.

Managed care makes the physician the "gatekeeper" whose duty it is to prevent patients from too easy access to specialists, hospitals or laboratories. When these restrictions result in denial of truly unnecessary care--that is, care that does not change the natural history of the disease in some effective way--they are morally justifiable, even mandatory. This is "managed care" in its best sense. Unfortunately, managed care as it is presently organized is just as likely to result in deprivation of needed care. It is "managed" not for patient benefit but for investor interests.

A Christian ethic of care focuses first on the sick person, the one in need, now presenting herself to the physician or nurse. The sick person is Christ himself seeking help. Some significant degree of effacement of self-interest is an inescapable obligation of physicians who see health care as a vocation and a form of ministry. For Christians the practice of medicine is an obligation of the stewardship the physician exercises over medical knowledge.

As Ecclesiasticus tells us: "Healing itself comes from God the Most High like a gift received from a King.... He has also given some people knowledge so that they may draw credit from his mighty works." In the Christian view, medical knowledge is knowledge held in trust. It is knowledge God has built into nature which humans may exploit to help and to heal one another. To be sure, physicians are entitled and indeed obliged to provide for themselves and their families. But this cannot be the primary motivation for a Christian apostolate of healing.