A basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients

Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, the American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients.     

Bluffing, puffing and spinning in managed-care organizations

I argue that because bluffing, puffing, and spinning are features of corporate life, they are likely to characterize the doctor-patient relationship in managed care medicine. I show that managed-care organizations (MCOs) and the physicians who contract with them make liberal use of puffing and spinning. In this way, they create a context in which it is likely that patients will also use deceptive mechanisms. Unfortunately, patients risk their health when they deceive their doctors. Using the warranty theory of truth I argue that although bluffing may be ethical in business because all participants agree to it and business has not warranted truth-telling, it is not ethical in a medical context because physicians and MCOs have warranted truth-telling and the quality of medical care depends on it.     

Ethical issues in the managed care setting: a new curriculum for primary care physicians

Several challenging ethical issues have been associated with the shift to managed healthcare in the United States. Our objective was to develop, implement, and evaluate a curriculum designed to help physicians identify and examine ethical issues encountered in the managed care setting. The curriculum was developed during a year-long workshop at Johns Hopkins Bayview Medical Center. The content of the curriculum was established through literature review, focus group discussions with physicians, and a needs assessment of targeted learners (primary care physicians practicing in managed care settings). Some of the key issues addressed in the curriculum include: changing professional responsibilities of physicians; fair use of resources; and threats to the doctor-patient relationship as a consequence of the new healthcare delivery system. The 7.5-h curriculum was taught over five sessions using varied teaching methods. Evaluations demonstrated that the curriculum was successful in increasing learner awareness of ethical issues confronted in the managed care environment and improved learner knowledge in these areas. The physician-learners reported that this educational experience would change their teaching of medical students and residents. After completing the curriculum, learners felt that they were at least somewhat better able to cope with ethical challenges encountered in the managed care setting. Future research might examine whether such a curriculum could positively affect physician behavior or enhance physician satisfaction with the managed care setting.     

Two concepts of medical ethics and their implications for medical ethics education

People who discuss medical ethics or bioethics come to very different conclusions about the levels of agreement in the field and the implications of consensus among health care professionals. In this paper I argue that these disagreements turn on a confusion of two distinct senses of medical ethics. I differentiate (1) medical ethics as a subject in applied ethics from (2) medical ethics as the professional moral commitments of health care professions. I then use the distinction to explain its significant implications for medical ethics education. Drawing on the recent work of John Rawls, I also show the centrality of philosophy in medical ethics by illustrating how contemporary philosophy can be used to construct an ethical framework for the medical professions.     

The best laid plans: resistant community and the intrepid vision in the history of managed care medicine

In the move to critique managed care, the essential principles that first made it a reasonable alternative to fee-for-service medicine can easily be lost. Careful reflection on the history of early grassroots movements that created managed care, and on selected textual narratives of the founders of the managed care organizations at their inception, offers us insight into which of the critical premises and goals of that effort might be reclaimed as we analyze the current managed care environment.     

Lifestyles of the Risky and Infamous From Managed Care to Managed Lives

As managed care organizations provide an increasing proportion of citizens' health care, the move toward asking individuals to help control costs by taking more responsibility for their health is likely to intensify. Economic, medical, and legal responses to lifestyle-induced health care costs raise concerns as well as possibilities for using resources responsibly.     

Paternalism, consent, and the use of experimental drugs in the military

Modern military organizations are paternalistic organizations. They typically recognize a duty of care toward military personnel and are willing to ignore or violate the consent of military personnel in order to uphold that duty of care. In this paper, we consider the case for paternalism in the military and distinguish it from the case for paternalism in medicine. We argue that one can consistently reject paternalism in medicine but uphold paternalism in the military. We consider two well-known arguments for the conclusion that military organizations should not be entitled to use experimental drugs on troops without first obtaining the informed consent of those troops. We argue that both of these are unsuccessful, in the absence of an argument for the rejection of paternalism in the military altogether. The case for military paternalism is widely accepted. However, we consider three ways in which it could be challenged.     

So-called "clinical equipoise" and the argument from design

In this article, I review and expand upon arguments showing that Freedman's so-called "clinical equipoise" criterion cannot serve as an appropriate guide and justification for the moral legitimacy of carrying out randomized clinical trials. At the same time, I try to explain why this approach has been given so much credence despite compelling arguments against it, including the fact that Freedman's original discussion framed the issues in a misleading way, making certain things invisible: Clinical equipoise is conflated with community equipoise, and several versions of each are also conflated. But a misleading impression is given that, rather than distinct criteria being arbitrarily conflated, a puzzle is solved and a number of features unified. Various issues are pushed under the rug, hiding flaws of the "clinical equipoise" approach and thus deceiving us into thinking that we have a solution when we do not. Particularly significant is the ignoring of the crucial distinction between the individual patient decision and the policy decision.     

Cost Containment,DRGs, and The Ethics of Health Care

This series of articles by Charles Dougherty, Robert Berenson, and Kathleen Powderly and Elaine Smith, as well as “Cost Containment: Challenging Fidelity and Justice” by E. Haavi Morreim (Hastings Center Report, December 1988), result from a Hastings Center project, “Ethics and Prospective Payment Systems: DRGs.” The two-year project was jointly funded by The General Electric Foundation and the American Medical Association Education and Research Foundation. The project tried to gauge the systematic effects of the introduction of cost containment strategies, prospective payment by Diagnostic Related Groups in particular, on the provision of health care and the ethical practice of medicine. Cost containment strategies, no matter how necessary in curbing spiraling medical costs, leave no sector or participants in the health care system untouched—hospitals and other health care institutions; doctors, nurses, social workers and other health care professionals; patients, their families, and the thirty-six to forty million medically indigent. The articles discuss the several and interrelated ethical issues raised by the DRG prospective payment system (Dougherty); its particular affect on the doctor-patient relationship and how it is transforming the ethical practice of medicine (Berenson and Morreim); and its specific impact on the professions and professional ethics of nursing and social work (Powderly and Smith). The overall message of the articles is that the health professions, their provision of care, and the ethics of their practices—as driven by economic considerations and realities—are in the midst of a more or less radical sea change.     

Ethical challenges of chronic illness

This Hastings Center Report supplement is derived from the Center's three-year "Ethics and Chronic Illness" project. The project was premised on the idea that chronic illness is a distinctive experience, and that chronic care is different in nature from the acute care that is the current focus of American medicine. In our aging society, the prospect of widespread disability and chronic illness is "a spectre haunting the American health care system." The reality of chronic illness could transform many pervasive assumptions about medical goals and ethics. With this report, the authors intend to stimulate a broader discussion of the ethical issues distinctive to chronic illness, and to outline an agenda for future bioethical investigation. They also hope to articulate the rudiments of a moral vision to guide the health care system, welfare services, families, and communities as they face the challenges of providing chronic care.     

Critical care in the Philippines: the "Robin Hood Principle" vs. Kagandahang loob

Practical medical decisions are closely integrated with ethical and religious beliefs in the Philippines. This is shown in a survey of Filipino physicians' attitudes towards severely compromised neonates. This is also the reason why the ethical analysis of critical care practices must be situated within the context of local culture. Kagandahang loob and kusang loob are indigenous Filipino ethical concepts that provide a framework for the analysis of several critical care practices. The practice of taking-from-the-rich-to-give-to-the-poor in public hospitals is not compatible with these concepts. The legislated definition of death and other aspects of the Philippine Law on Organ Transplants also fail to be compatible with these concepts. Many ethical issues that arise in a critical care setting have their roots outside the seemingly isolated clinical setting. Critical care need not apply only to individuals in a serious clinical condition. Vulnerable populations require critical attention because potent threats to their lives exist in the water that they drink and the air that they breathe. We cannot ignore these threats even as we move inevitably towards a technologically dependent, highly commercialized approach to health management.     

Who Is “Too Sick to Benefit”?

Intensive care units provide focused, aggressive medical intervention to critically ill patients. Physicians responsible for ICU triage must decide which patients are sick enough to require this level of care and which can be managed on the general wards. While some patients are too well for the ICU, intensivists increasingly rely on another category, “too sick to benefit,” when denying ICU admission, even if beds are readily available. Recent studies indicate that between 19 and 37 percent of patients refused ICU admission were declined because they were thought too sick to benefit from it, suggesting that physician use of this category is common in ICU triage. The idea of being too sick to benefit may seem paradoxical given that ICUs exist to treat the sickest of the sick. There is, however, increasing awareness that some diseases progress despite maximal intervention. Although there have been systematic attempts to define these diseases—most notably during the medical futility debates of the 1980s and early 1990s—there is little evidence about which conditions make a patient too sick to benefit from ICU admission. In the absence of a clear understanding of which diseases progress despite maximal care, ICU triage under the category “too sick to benefit” is currently done on a case‐by‐case basis. Contemporary decisions about who is too sick to benefit thus raise a number of ethical issues about what constitutes standard of care, the role of health care providers' judgments of quality of life in triage, and the just allocation of resources. Addressing these ethical concerns requires us to better define the population of critically ill adults who are too sick to benefit—a conceptual and empirical project. In this article, I recommend employing a diagnostic concept from the neonatal literature: namely, a lethal disease.     

Pedagogical Support for Responsible Conduct of Research Training

The number of training programs for the responsible conduct of research (RCR) has increased substantially over the past few decades as the importance of research ethics has received greater attention. It is unclear, however, whether the proliferation of RCR training programs has improved researcher integrity or the public's trust in science. Rather than training researchers simply to comply with regulations, we could use the opportunity to develop researchers' ability to understand and appreciate the ethical ideals that inform the regulations in order to help them integrate ethical decision‐making into their work on a regular basis. Incorporating ethical principles into research training requires a new way of teaching RCR and the development of support materials to facilitate its adoption. The Presidential Commission for the Study of Bioethical Issues, a panel established to advise the President on bioethical issues arising from advances in biomedicine and related areas of science and technology, developed and provides pedagogical materials based on its published reports to facilitate the integration of ethics education across the curriculum and in support of RCR and general bioethics education.     

Managed care and the ethics of regulation

The dramatic appearance of managed care organizations (MCOs) on the U.S. health scene has generated tremendous anxiety among health care providers and patients. These fears are based on the belief that managed care techniques pose greater risks of under treatment than do fee-for-service modes of payment. In addition, many physicians and patients resent the limits placed on clinical autonomy by the MCO model and the stresses that it places on the traditional physician-patient relationship. These misgivings have been exacerbated by the mostly negative response to MCOs in the media and academia. Legislatures have responded to these claims and public fears with a wave of regulatory initiatives. Some of these regulations are attempts to protect patients. Others, however, are motivated primarily by antipathy toward the concept of managed care itself. This essay is an attempt to develop a social ethic of regulation and argues that the sole reason that private enterprise may be justifiably limited is when it presents a risk of harm to others or society. While some regulation and proposed regulation of MCOs meet this standard, much legislation represents an unjustified attempt to limit or handicap otherwise legal behavior merely because a segment of the population and medical profession find it aesthetically unpleasing and oppose its approach to the delivery of health services.     

Pediatric Drug Labeling and Imperfect Information

I first became aware of bioethics in the spring of 1980. I had spent a thirty-six-hour shift shadowing a medical resident, and I was struck that many of the resident's decisions had ethical dimensions. The next day, I came across the Hastings Center Report, and I realized I wanted to explore ethical issues I found implicit in clinical care, even though I still wanted to become a pediatrician. In September 2019, when I attended my first meeting of the U.S. Food and Drug Administration's Pediatric Advisory Committee, as a pediatric pulmonologist, I had the same sense of awe and curiosity that I had forty years ago. What had appeared initially as somewhat technical decisions about the regulation of drug labeling was suffused with ethical questions. The committee was asked to discuss possible changes to the labeling of two previously approved drugs.     

Ethical responsibility in the German Democratic Republic

The chairman of the German Democratic Republic's (GDR) Committee on Medical Ethics, the Council of Medical Sciences, reviews issues of ethical concern to East German medicine. According to Tanneberger, ethical conflicts in health care are avoided in the GDR largely due to the socialist nature of public services. Ethical problems in medicine primarily involve research with human subjects, with animal experimentation and implementation of biomedical technologies as topics of interest as well. A nationwide system of ethical guidance and control has been created, headed by the Council of Medical Sciences and including the scientific councils of the individual medical disciplines and of the main research projects supported by the state, as well as the faculties of the medical universities. Tanneberger emphasizes that in the GDR, the intention is to develop a sense of responsibility among all those involved in medical research, rather than to impose a regulatory system.     

Medical School: The Wrong Applicant Pool?

Evidence‐based medicine has become both the mantra of clinical practice and the dominant contemporary approach to patient care. Gordon Guyatt et al. first proposed applying the concept to medical education in the early 1990s, arguing for training that “de‐emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale” in favor of “examination of evidence from clinical research”; over the following twenty‐five years, nearly every medical school and residency program in the United States incorporated these methods into its training. During this same period, admissions requirements and protocols have continued to rely on subjective, non‐evidence‐based ideals largely developed a century earlier. In light of the continued underrepresentation of certain demographic groups among matriculants, as well as the national controversy surrounding admissions standards at undergraduate institutions—most notably embodied in the lawsuit by Students for Fair Admissions against Harvard University—the moment may be ripe for a radical reexamination of those requirements.     

Introduction to the theme

Spicker introduces a set of five articles on medico-economic, ethical, and conceptual problems raised by the new Medicare prospective payment system (PPS), which bases reimbursement of hospitals on treatment of patients in disease categories known as diagnosis related groups (DRGs). The articles are by Charles E. Begley ("Prospective payment and medical ethics"); George J. Agich ("Incentives and obligations under prospective payment"); Thomas Halper ("DRGs and the idea of a just price"); Leonard M. Fleck ("DRGs: justice and the invisible rationing of health care resources"); and Edmund L. Erde ("Efficiency, ethics and indigent care: a review of the proceedings of the conference 'The all-payers DRG system: has New Jersey found an efficient and ethical way to provide indigent care?").     

One or two: an examination of the recent case of the conjoined twins from Malta

The article questions the assumption that conjoined twins are necessarily two people or persons by employing arguments based on different points of view: non-personal vitalism, the person as a sentient being, the person as an agent, the person as a locus of narrative and valuation, and the person as an embodied mind. Analogies employed from the cases of amputation, multiple personality disorder, abortion, split-brain patients and cloning. The article further questions the assumption that a conjoined twin's natural interest and wish is separation. I first contend that separation is such a radical procedure as to render the post-separation person different from the pre-separation one. Therefore, it is not possible to benefit the pre-separation twin by the act of separation. The article concludes with a critical evaluation of the tendency in bioethics to regard ethical challenges as rivalry between individuals competing for scarce resources.     

Fatal Knowledge? Prenatal Diagnosis and Sex Selection

Moral and social arguments weigh heavily against performing medical procedures solely for purposes of sex selection. The medical profession has a responsibility to abandon its posture of ethical neutrality and take a firm stand now against sex selection.