WASHINGTON--The shift in health-care delivery methods from fee-for-service
to managed care may bring with it troubling shifts in medical
In today's era of managed care, the physician may have responsibility
to two agents--the patient and the payer, said Deborah Whisnand,
MA, ThM, a medical ethicist for Bioethics Consultants, Berkeley,
Calif. This creates tension between delivering the best care to
the patient while satisfying the economic needs of the contracting
"We are beginning to move from offering the absolute best
care to the patient to offering the assurance of good care, not
just adequate, but good care," Ms. Whisnand said. "We
are in an era where we will no longer, because of limitations,
be able to provide best care in every instance."
Speaking at the Association of Community Cancer Centers meeting,
Ms. Whisnand described some of the ethical shifts that have occurred
in health-care delivery in the past.
In the Hippocratic era, the physician made judgments based on
experience. The patient rendered authority to the physician, and
the physician's sole duty was to the patient, who paid him directly.
The shift to the Medicare era in the 1940s involved two important
events--the beginning of third-party payment and the scientific
era in medicine. The physician now had to draw on science, not
just observation and experience, and would be judged by external
Medicare was created, and the health insurance industry began
to expand as employers began to include health care as a benefit.
Patient expectations rose, and litigation increased. By the 1970s,
third-party payments comprised more than 50% of health-care payments.