Ethical challenges for doctors in managed care

By Jean Edwards Holt, MD, FACS

San Antonio, TX

In today’s politically correct jargon, it may be said that physicians are "ethically challenged." As a result of the most recent government attempt at sweeping health care reform in 1993, followed by the aggressive takeover mode of Wall Street, physicians today are facing challenges in their profession as never before. At stake is their power, their privilege, their patients, and their pocketbooks. The generally accepted professional principle of doing everything possible for each patient without concern for the system or, in particular, the cost, is being challenged.

Managed care incorporates both the businessman’s expectations to economically salvage the American medical profession and the physician’s warning of impending doom. Managed care is being put into place to reevaluate, redesign, and re-engineer existing health care processes in order to maintain or improve clinical outcomes, quality, and services at a reduced cost — a lofty goal, indeed. In the face of this changing environment, physicians must know their past. They must admit that change, though feared and oftentimes resented, may bring progress. And they must devote time and energy to meeting the challenges ahead.

One of the primary tools used to manage health care is creating a financial conflict of interest, pitting the physician’s fiduciary responsibility for the patient (the cornerstone of medical ethics) against his or her economic survival. Conflicts have existed in the past but have heretofore economically favored the physician. This great challenge of what is "right" and what is "expected" when they may no longer be equivalent places the physician under a cloud of confusion and stress.

The physician must carry the banner of professional ethics into this new world of businessmen, lawyers, and managers; understand the conflicts threatening our profession; but hold it steadfast and maintain higher standards than ever before. These challenges must be faced as an opportunity to improve existing weaknesses and to provide the highest quality ethical health care possible for the American people.

The historical establishment of the beneficence of medical ethics is generally unquestioned and universally accepted. The ethical standards of right and wrong do not change as technical treatment options might; that is, what was therapeutically done yesterday may be found to be inappropriate tomorrow.

Adherence to ethical standards, however, has varied depending upon the pressures of litigation, competition, and consumerism. The practice of medicine is clearly a social task. Medical ethics, therefore, cannot be truly separated from societal ethics. In a very broad sense, a physician can only practice ethically in an ethical institution, and ethical institutions can only be maintained in a just society.

Under our old system with cost of little or no concern, there have been few ethical issues raised related to denying or rationing care. However, ethical conflict is present, as paying fiduciaries is per se ethically unstable. This ethical instability is not cured but merely managed, either well or poorly. In the setting of economic abundance, it has been managed rather poorly. Of key importance is the understanding that this economic conflict of interest favored the physician — that is to say, more tests, more examinations, and more hospital admissions, did not inherently detract from the physician’s income.

Presently, the fundamental concept of the profession as a fiduciary is being destabilized. Physicians may be forced to choose between the best interest of the patient and their own economic survival. If this is allowed to happen, it could lead to the breakdown of the concept of medicine as a fiduciary profession in its true ethical sense.

The profession will not preserve itself alone, but must work in cooperation with society as a whole to do so. Physicians must continue to care for individual patients while considering the good of society and still not violate the classic physician/patient relationship.

Patients must be appraised of the ethical and moral limitations being currently placed on physicians and must understand the implications for their own care. It is popular for physicians to claim that ethics can be reduced to law, rules and regulations. This is simply shifting responsibility for what is "right" to areas outside the profession where there is significant mistrust for guidance in our daily lives.