Yes, Managed Care Can Be Ethical

George L. Spaeth, MD
Article Type: 
January/February 1999
Volume Number: 
Issue Number: 

Dear Dr. Gervais:
Thanks for your note of February 29, which was forwarded to me by Ophthalmology World Times. You posed a few questions.

First, you wonder, is it ethical for physicians to support the theoretical underpinnings of managed care, whose goal is to view the sick patient as a liability rather than an asset? By definition, the answer to that is “no.” But you have phrased the question in a way that only one answer is possible. How about changing the question so it reads: “Is it ethical for physicians to support the theoretical underpinnings of a managed care system whose goal is to convince doctors to view the sick patient as an asset rather than a liability?” Or, how about asking the question in the following way: “Is it ethical for physicians to support the theoretical underpinnings of a fee-for-service system whose goal it is to convince doctors that patients can make them rich?” The answer to the second question is “yes.” A managed care system can be ethical. The answer to the third question is “no.” A fee-for-service system, which is designed to separate patients from their money for the purpose of the practitioner, is not ethical.

Your second question asks: “Is it ethical for physicians to join the managed care bandwagon when the latter contrives to keep patients ignorant of the fact that doctors must abandon the mindset of the classical physician, who prospers by treating the sick, in order to adopt the mindset of the insurance executive, who loses financially when confronted with a sick patient?” Again, by definition, the answer to that question is “no.” Of course, it is not ethical to adopt the methodologies of a system which is not designed to benefit the patient.

The three principles that are used to judge whether an act is ethical are: (1) autonomy; (2) beneficence, non-maleficence; and (3) justice. The degree to which a medical action is ethical is measured in terms of the degree to which it enhances the patient’s autonomy, benefits and does not harm the patient, and is just.

The question that you pose gets at something that is really important! It is not the insurance company that forces us to adopt a mindset in which being a benefit to the patient is not one of the physician’s primary concerns. The insurance company may say, “Unless you adopt that mindset, we won’t let you play in our ballpark.” That is their right. In fact, they’d be foolish not to design their system in a way that was going to produce the maximum profit for them. That’s their reason for existence. When a physician joins such an insurance plan, the question has to be asked: “Isn’t the physician adopting exactly the same motivation as the insurance company?” The answer is “yes.” So, it’s not the insurance company who should be considered at fault; it is the physician who agrees to practice in a way that is not in the best interest of the patient, who is acting unethically.

But what does the physician do when all the insurance plans require the physician to act unethically? After all, a physician has to make a living. The simple, correct answer is, unfortunately for physicians, the easy answer. The physician simply does not join such a program and simply does not agree to practice in such an insurance system. If all physicians resisted signing up with programs that ask them to act unethically, no insurance program that required physicians to act unethically could survive. It is the fact that some physicians sign up for such programs that puts pressure on other physicians who don’t want to sign up but feel they have to. It is, then, the complicity of the physician that allows the unethical system to prosper.

Your third question asks: “Is it unethical for managed care to cease engaging in mutually beneficial exchanges with patients when history has clearly shown that interference with mutually beneficial exchanges end in failure? (A patient hopes to ‘win’ by obtaining a cure in exchange for cash and the classical doctor hopes to ‘win’ by curing the ill; in managed care, the patient hopes to win by obtaining a cure, but a doctor ‘loses’ financially when providing a cure.)” Again, the way you’ve phrased the question clearly determines the answer. You suggest that there’s something inherent in the managed care setting that requires the physician to lose financially when providing a cure, whereas in the fee-for-service system there’s never a problem in this regard. It’s not difficult to put a very different face on that.

The fee-for-service system encourages the physician to perform procedures, because the physician benefits. Furthermore, there isn’t a huge incentive in producing a real cure, because then the patient disappears and the physician never gets any further income from that patient. In contrast, there’s a greater reason for the physician to try to cure a patient when every subsequent visit is going to cost the physician something. That is, it’s easy to make the fee-for-service system the culprit and the managed care system the hero, depending upon how the various systems actually work.

To summarize: Physicians are responsible for their behavior. They are responsible for the plans that they agree to sign or for which they agree to work.

When some physicians act unethically, their unethical behavior not only damages patients, but damages the entire profession and damages other physicians too. Unfortunately, physicians often don’t realize this. If they did, they would be far more vigilant in insisting upon ethical behavior by all physicians and would be far more willing to cooperate with groups such as the Ethics Committee of the American Academy of Ophthalmology and would be far less likely merely to carp at those with whom they disagree and hide in the apparent safety of anonymity. In fact, it is the unwillingness of physicians to insist upon ethical behavior by all members of the profession that results in damage to all members of the profession, including those who are practicing ethically.

Dr. Gervais, you’ve posed all your questions in a way that anyone who really cared for patients would have to answer the questions the way you want the questions to be answered. But the problem isn’t in the system, the problem is in us.

[Read Dr. Gervais' counterpoint commentary]

Dr. Spaeth is an ophthalmologist at Wills Eye Hospital in Philadelphia, PA. His address is 900 Walnut Street, Philadelphia, PA 19107-5598, (215) 928-3000.

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