Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay.The term managed care describes a diverse set of organizational forms. Wide variations in approach, financing, physician involvement, and (...) philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay. The term managed care describes a diverse set of organizational forms. Wide variations in approach, financing, physician involvement, (...) and philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

The patient was a woman in her 30s who, until the rapid progression of an ultimately fatal neurologic disease, had been a very successful professional, enjoying athletics and an active social life. In the 6 months of swift deterioration, she had gone from being extremely vibrant and energetic to being totally unable to care for her personal needs. There had been no loss of intellectual capacity. Her sister later recounted to Dr. J., the emergency department physician, that she had found (...) the patient unconscious and unresponsive at home and had immediately called the patient's neurologist in a neighboring city. He directed her to call the paramedics. (shrink)

As the structure of healthcare delivery undergoes a breathtaking transformation, many ethics committees are wondering how and if they will be affected. Although the impact has not yet been widely felt, hospital-based ethics committees cannot avoid the pressures and upheaval caused by the reorganization of healthcare. This article will briefly review some of the factors contributing to the transformation of medicine, and suggest a number of ways in which ethics committees can respond proactively.

Oregon is the only state in the United States where a physician may legally prescribe a lethal dose of barbiturate for a patient intending suicide. The Oregon Death with Dignity Act was passed by voters in 1994 and came into effect after much legal wrangling in October of 1997. At the same time, a cabinetmaker named Pat Matheny was struggling with progressive weakness from amyotrophic lateral sclerosis, or ALS. I met with Pat and his family for a lengthy interview in (...) October 1998 in Coos Bay, Oregon, for a television news report on his decision to get a lethal prescription. Below is an extract from that interview. On the day this introduction was written, 10 March 1999, Pat took the prescribed lethal overdose of barbiturates and died at home. His illness was taking his voice, he could not move his hands or legs, and breathing was becoming very difficult. His mother told me he knew that was for him. (shrink)