Medical ethics under managed care.

P Schwartz
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Abstract

"Managed Care" is having a profound effect on medical ethics and the patient/physician relationship. Historically, the patient (the first party) contracted with a physician (the second party) to provide medical care. The physician had ethical and legal obligations to the patient. In the "new health care," an employer or the government (the fourth party) or infrequently, the patient (the first party) purchases health care from the HMO, PPO, or similar organization (the third party). The third party then contracts with the physician (the second party) to provide that care. The physician has agreed to two, at times competing and possibly immutably conflicting obligations--one to the patient and one to the third party. The ethical and legal problems that arise from conflict between "the bottom line" and "desired" (appropriate) health care will be difficult to solve. The incompatible duality of physician roles both as patient advocate and manager of limited resources will be further explored, with attention to the enormous pressure being applied to this conflict by society, the law, and the third party. Potential resolutions will be offered. Other ethical problems created by the health care system's conversion to managed care include: CONFIDENTIALITY--Information management is a fundamental underpinning of managed care. With patients switching health care programs frequently, and their enormous size and complexity, careful attention to confidentiality is necessary. INFORMED CONSENT--In addition to informed consent relative to the health care being offered, the patient has a right to know what alternatives might be offered independent of her insurance and payment plan. The patient also has a right to know the economic pressures and arrangements between the second and third parties that could influence the quantity and quality of her health care. QUALITY OF CARE--Managed care contends to be religiously attentive to quality of care. If this is so, the very definition of quality of care may be changing.

管理式医疗下的医学伦理。
“管理式医疗”正在对医学伦理和医患关系产生深远的影响。从历史上看,病人(第一方)与医生(第二方)签订了提供医疗服务的合同。医生对病人负有道德和法律上的义务。在“新型医疗保健”中,雇主或政府(第四方),或者很少的情况下,患者(第一方)从HMO、PPO或类似组织(第三方)购买医疗保健。然后,第三方与医生(第二方)签订合同,提供这种护理。医生已经同意了两项有时相互竞争、可能永远相互冲突的义务——一项是对病人的义务,另一项是对第三方的义务。由于"底线"和"期望的"(适当的)保健之间的冲突而产生的伦理和法律问题将难以解决。医生作为患者倡导者和有限资源管理者的不相容的双重角色将进一步探讨,并关注社会,法律和第三方对这种冲突施加的巨大压力。可能的解决方案将会提出。医疗保健系统向管理式医疗的转变所产生的其他伦理问题包括:保密——信息管理是管理式医疗的基本基础。由于患者频繁更换医疗保健计划,而且这些计划的规模和复杂性都很大,因此对保密问题的谨慎关注是必要的。知情同意————除了与所提供的医疗保健有关的知情同意外,患者有权知道在其保险和付款计划之外可能提供哪些替代方案。患者还有权了解第二方和第三方之间的经济压力和安排,这些压力和安排可能会影响到其医疗保健的数量和质量。护理质量——管理式护理声称对护理质量非常关注。如果是这样的话,医疗质量的定义可能正在改变。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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