Rationing and Professional Autonomy

Aday Lu Ann , “The Ethical Implications of Prospective Payment and Corporate Medical Practice: A Research Agenda,” Social Justice Research, 1 (1987): 275–295; Agich George J. , “Incentives and Obligations Under Prospective Payment,” Journal of Medicine and Philosophy, 12 (May 1987): 123–144; Agich George J. and Begley Charles E. , “Some Problems with Pro-competition Reforms,” Social Science and Medicine, 21 (185): 623–530; Begley Charles E. , “Prospective Payment and Medical Ethics,” Journal of Medicine and Philosophy, 12 (May 1987): 107–122; Berenson Robert A. , “A Physician's Reflections,” Hastings Center Report, 19 (January/February 1989): 12–15; Dougherty Charles J. , “Ethical Perspectives on Prospective Payment,” Hastings Center Report, 19 (January/February 1989): 5–11; Morreim E. Haavi , “The M.D. and the DRG,” Hastings Center Report, 15 (June 1985): 30–38; Morreim E. Haavi , “Cost Containment: Issues of Moral Conflict and Justice for Physicians,” Theoretical Medicine, 6 (1985): 257–279; Powderly Kathleen E. and Smith Elaine , “The Impact of DRGs on Health Care Workers and Their Clients,” Hastings Center Report, 19 (January/February 1989): 16–18; and, Veatch Robert M. , “DRG's and Ethical Reallocation of Resources,” Hastings Center Report, 16 (June 1986): 32–40.

Empirical work to date has demonstrated the complexity of the issues underlying these claims. See, for example, Hillman Alan L. , “Financial Incentives for Physicians in HMOs,” New England Journal of Medicine 317 (December 1987): 1743–1748 and “How Do Financial Incentives Affect Physicians' Clinical Decisions and the Financial Performance of Health Maintenance Organizations?” New England Journal of Medicine 321 (1989): 86–92; ICF, Incorporated, “Study of Incentive Arrangements Offered by HMOs and CMPs to Physicians: Final Report,” unpublished report prepared for the Office of the Assistant Secretary for Planning and Evaluation, DHHS, 1988 and, U.S. General Accounting Office, “Physician Incentive Payments by Prepaid Health Plans Could Lower Quality Care,” Report to the Chairman, Subcommittee on Health, Committee on Ways and Means, House of Representatives, December, 1988.

Freidson Eliot P. , Profession of Medicine (New York: Harper &Row Publishers, 1970), 71–84.

May William F. , “Code, Covenant, Contract, or Philanthropy,” Hastings Center Report, 5 (1975): 34.

Pellegrino Edmund D. and Thomasma David C. , A Philosophical Basis of Medical Practice (Oxford: Oxford University Press, 1981), 207–209.

Ibid., p. 210

Ibid., p. 211

Buchanan Allen , “Principal/Agent Theory and Decision Making in Health Care,” Bioethics, 2 (October 1988), 323.

Pellegrino Edmund D. , “Medical Morality and Medical Economics,” Hastings Center Report, 8 (August 1978): 8–12.

I have discussed these concerns in some detail in Agich, “Incentives and Obligations Under Prospective Payment.”

Buchanan , “Principal/Agent Theory and Decision Making in Health Care,” 323.

Ibid., 318.

The classic economic explanation of this conflict of interest is Arrow Kenneth J. , “Uncertainty and the Welfare Economics of Medical Care,” American Economic Review, 53 (December 1963), 941–973. For a critical discussion of this argument see Agich, “Medicine as Business and Profession,” Theoretical Medicine, in press.

Relman S. Arnold , “The Future of Medical Practice,” Health Affairs, 2 (Summer 1983), 5–19.

Ibid., 8.

Ibid., 6

Section VI of the current Principles of Medical Ethics (1980) of the American Medical Association reads as follows: “A physician shall, in the provision of appropriate patient care except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical service.”

Morreim , “Cost Containment: Issues of Moral Conflict and Justice for Physicians,” Ibid., 268–269.

Begley , “Prospective Payment and Medical Ethics,” Ibid., 116.

Menzel Paul T. , Medical Costs, Moral Choices: A Philosophy of Health Care Economics in America (New Haven: Yale University Press, 1983).

Daniels Norman , “Why Saying No to Patients in the United States is So Hard,” New England Journal of Medicine, 314 (May 22, 1986), 1382.

Ibid., 1383

Hiller Marc D. and Gorsky Robin D. , “Shifting Priorities and Values: A Challenge to the Hospital's Mission,” in Agich George J. and Begley Charles E. eds., The Price of Health (Dordrecht, Holland: D. Reidel Publishing Co., 1986), 245–261 and Starr Paul , The Social Transformation of American Medicine (New York: Basic Books Inc., Publishers, 1982).

Cushing Harvey , Consecratio Medici and Other Papers (Boston: Little Brown, 1928), 3–13.

Newhauser Duncan and Stason William B. , “Cost-Effective Clinical Decision Making,” Carels N.J. eds., The Physician and Cost Control (Cambridge, MA: Olegeschlager, Gunn &Hain, Inc., 1979), 134.

This taxonomy and interpretation are drawn from E. Richard Brown, “DRG's and the Rationing of Hospital Care,” Anders G. R. and Glesnes-Anderson V. A. , eds., Health Care Ethics (Rockville, Maryland: Aspen Publications, 1987), 69–90.

Arrow , “Uncertainty and the Welfare Economics of Medical Care, Ibid.

Physician Payment Review Commission, Annual Report to Congress (Washington, D.C., 1989), 276.

Epstein A. M. , “The Use of Ambulatory Testing in Prepaid and Fee-For-Service Group Practices: Relation to Perceived Profitability,” New England Journal of Medicine, 314 (1986): 1089–1094; Manning W. G. , “A Controlled Trial of The Effect of a Prepaid Group Practice on Use of Services,” New England Journal of Medicine, 310 (June 7, 1984): 1505–1510; and Wells K. B. , “Use of Out Patient Mental Health Services in HMO and Fee-For-Service Plans: Results from a Randomized Controlled Trial,” Health Services Research, 21 (August 1986) 453–474.

Sloss E. M. , “Effect of a Health Maintenance Organization on Physiologic Health: Results From A Randomized Trail,” Annals of Internal Medicine, 106 1987): 130–138: Ware J. E. , “Comparison of Health Outcomes at a Health Maintenance Organization with Those of Fee-For-Service,” The Lancet (May 3, 1986): 1007–1022.

Annual Report to Congress, bid., 292.

Ibid.

Luft Harold , “Economic Incentives and Clinical Decisions,” in Gray Bradford H. , ed., The New Health Care For Profit (Washington, D.C.: National Academy Press, 1983) 103–123.

Ibid., 115–116.

Ibid., 117

Wennberg John E. , “Dealing with Medical Practice Variations: A Proposal For Action,” Health Affairs, 3 (Summer 1984): 632 and Wennberg John E. , “Will Payments Based on Diagnosis-Related Groups Control Hospital Costs?” New England Journal of Medicine, 311 (August 2, 1984): 295–300.

“In treating a terminally ill or irreversibly comatose patient, the physician should determine whether the benefits of treatment outweigh its burden.” American Medical Association Statement on Withholding or Withdrawing Life Prolonging Medical Treatment (1986).

The notable exception is the inclusion for the first time of rights language in Section IV of the American Medical Association's Principles of Medical Ethics (1980): “A physician shall respect the rights of patients, of colleagues, and of other health professionals and shall safeguard patient confidences within the constraints of the law.”