‘DISTRIBUTIVE’ MEDICINE: New Ethic Under Managed Care?

      In an editorial in this week's New England Journal of Medicine, editor Dr. Jerome Kassirer addresses the question of whether physicians should "make caring for their entire group of patients a higher priority than caring for each individual patient." He notes that under managed care, physicians are expected to "adopt what has been called a distributive ethic, in which the principle is to provide the greatest good for the greatest number of patients within the allotted budget." Kassirer asks, "[H]ow can physicians provide optimal care for each of their patients and for the entire group at the same time? In agreeing to a distributive ethic, are physicians tacitly becoming agents of the plan instead of agents for their patients?" He then goes on to discuss the "population-based system of ethics," in which optimizing care for a group of patients, by setting a "minimally acceptable" level of care for each individual, is held to be ethical, even if some patients failed to receive "optimal care." He notes, "According to this view, it is acceptable for physicians to make differential medical judgments on the basis of patients' insurance coverage, as long as they acknowledge the basis for their recommendations." However, Kassirer argues that this argument should be rejected because "intentionally providing minimally acceptable care to some for the benefit of others in a arbitrary group -- let alone for the benefit of the bottom line -- is wrong," as is "[c]ustomizing care on the basis of a patient's insurance coverage."

It's No Excuse
      He also says that disclosing these arrangements does not provide a justification for accepting them. Kassirer urges physicians to keep their "moral commitment to each patient and to the integrity of the profession," by refusing to sign contracts that prevent full disclosure, and "refusing to participate in plans in which the financial risk is so great that they may be tempted to provide suboptimal care." He concludes: "If we capitulate to an ethic of the group rather than the individual, and if we allow market forces to distort our ethical standards, we risk becoming economic agents instead of health care professionals. Inevitably, patients will suffer and so will a noble profession" (Kassirer, NEJM, 8/6 issue).