Abstract

Recent efforts to control the rising cost of health care have included the use of physicians as gatekeepers. It is argued that physicians, who through their patient care decisions are accountable for up to 80 percent of health care costs, are in the best position to balance the needs of individual patients against the need to control costs. Such a dual role for physicians may be ethically problematic. If physicians assume the role of gatekeeper, then they may violate their more essential role as patient advocate. ;Yet rising costs themselves are of moral concern if they contribute to an unjust allocation of health care resources. Cost containment is a matter of justice if uncontrolled spending by some puts at risk the availability of resources for others. Do physicians have obligations of justice to help control costs? If so, how do they balance obligations of justice and patient advocacy? ;In attempting to answer this question, I display and criticize three major arguments against a role for physicians in cost containment. Chapter 1 includes an argument from the nature of medicine that depicts the patient/physician relationship as inherently individualistic. Chapter 2 focuses on an argument for the isolation of physicians from considerations of justice from within an ideal contract theory. Chapter 3 includes an analysis of an argument from the nature of professions that requires the existence of role-specific duties that take precedence over broader moral concerns. Chapter 4 includes an outline of a theory of the social responsibility of physicians. ;I argue that physicians cannot be exempt from considerations of justice and that physicians can be advocates for their patients and still consider costs. Such a balancing must occur within a broad social consensus about how resources are to be allocated. ;The social responsibility of physicians is grounded in an expanded understanding of persons that views persons as members of communities with obligations of sharing. Both physicians and patients have obligations of justice, and physicians are not ethically required to behave as though patients themselves did not have such obligations