Health Care Reform and the Future of Physician Ethics

Abstract

Health care reform proposals threaten to exacerbate tensions that physicians already face in trying to balance traditional duties to individual patients against increasing pressure to serve broader societal and institutional goals. The reform proposals thus heighten ethical concerns already with us thanks to large disparities in health care coverage, the rise of managed care, and the proliferation of organizations powerfully affecting patient treatment. Debate is essential, but currently lacking, on the future content of physician and organizational ethics in a reformed health care system.

This gap must be addressed for the reformed system to function effectively and ethically. This article analyzes the options for normatively structuring physician and organizational behavior. Physicians need to be able to forge effective doctor-patient relationships with the massive number of newly covered patients anticipated. Patients need adequate information, including on cost-containment strategies, with which to choose their health plan and primary care physician. Health plans and health care alliances, which will play a crucial role in securing access and controlling costs, should refrain from imposing organizational expectations that undermine physicians’ capacity to forge an effective treatment relationship and provide needed care. Physicians will play a pivotal role in translating the covered benefits package into treatment authorization decisions; this must be done transparently, with information to the patient about the full range of relevant treatment options (including those not covered by the plan), and with physician advocacy for needed care.

To cope with reform, medical ethics rnust clarify physicians’ moral obligations, change existing ethical codes, and develop an ethics of institutions. The article ultimately offers five concrete recommendations to guide physician and organizational ethics and behavior in a reformed system. To ignore physician ethics ensures severe problems in day-to-day practice and has the potential to undermine systemic reform itself. Modern bioethics came of age through detailed work on physician ethics. Now the larger ethics of system-wide reform takes center stage. Physician ethics stands to be deeply changed by health care reform, and reform demands a quantum leap in physician ethics.

Keywords: Health care reform, health plans, health care alliances, managed care, benefits package, doctor-patient relationship, physician ethics, conflicts of interest, medical ethics, organizational ethics, bioethics