Experts debate the ethical dilemmas of managed care

In an era of healthcare belt-tightening, the Jewish community must help Jews pay those critical medical expenses not covered by insurers, a prominent medical ethicist said at the recent International Conference on Jewish Medical Ethics in Burlingame.

"We will have to pick up the slack for what [health care providers] are not doing," Rabbi Moshe Tendler said.

In a lecture titled "Rights and Obligations in Managed Care," Tendler, a professor of biology and medical ethics at New York's Yeshiva University, said caring for the uninsured or underinsured is dictated by the Jewish principle of gemilut chesed, acts of lovingkindness.

Opportunities to perform such acts will surely increase in the rapidly changing world of medical care, Tendler said.

Already, many Americans have been forced to leave behind trusted doctors when their employers switch health-care plans. Health maintenance organizations go out of business, leaving clients to seek new HMOs or other managed-care plans. Doctors also change their affiliations from plan to plan.

These factors affect the quality of the precious doctor-patient relationship.

But while the changing American medical landscape has dramatically affected patients, physicians are also acutely familiar with the challenges of managed care. Last week physicians, health-care workers, rabbis and medical ethicists spent a morning at Burlingame's Park Plaza Hotel examining how managed care affects the delivery of medical care.

With for-profit firms capturing more of the managed-care market, many of the doctors agreed they face greater difficulty upholding ethical standards in their work.

For example, where doctors once answered to their patients, they are now forced to answer to the companies who allocate funds for care. This represents a major conflict of interest, said Dr. Rita Charon, associate professor of clinical medicine at the College of Physicians and Surgeons of New York's Columbia University.

In attempting to increase profits, those companies will often pressure physicians to limit their clinical services. If a physician doesn't behave like a "good HMO doctor," Charon said, he or she may find his or her livelihood threatened.

"You're not just the agent of the patient," Charon told the audience, "You're an agent of the shareholder. It's your duty to increase the dividends of the shareholder. It's the good of the patient versus the good of the firm."

Tendler went a step further, insisting there is no place in Jewish ethics for profit-motivated managed care. "The whole system is questionable," he said. "We don't need …to wholesale medical care."

He and others at the conference expressed concern that managed care — with its emphasis on the business of medicine — does not lend itself to compassionate medical treatment.

In addition, some questioned why doctors have generally failed to raise their voices to fight those aspects of managed care that they find objectionable.

"What the heck happened to the medical profession that they let this happen?" Tendler asked.

Charon theorized that doctors prefer to downplay the financial aspects of their work, and have thus been ashamed to come forth on the extent to which money and medicine are linked.

"Never before did doctors have to talk in public about their relationship to money," she said. "Up until now, we tried to make believe it didn't exist."

Another doctor suggested that managed care has polarized doctors, pitting primary care physicians against specialists. Thus it has been difficult, he said, for them to band together to express common grievances.

Dr. Laurence Marton added another factor to the mix: physicians' fear of biting the hand that feeds them. "There's great fear…that they will lose something," said Marton, a former dean of the University of Wisconsin-Madison Medical School.

But while those at the conference voiced their objections to managed care, some also took pains to point out those facets of managed care that can be beneficial. For one thing, Charon said, the restricted services offered by some managed care plans may ultimately lead people to clamor for universal health insurance for all.

The emphasis on preventive medicine encourages people to understand their bodies and take better care of themselves, which leads to improved general health, lower mortality rates and lower health-care expenditures. And because primary care physicians are often patients' main source of medical guidance, they tend to know patients' situations extremely well.

Primary care physicians "get to know their patients' bodies, get to know the sources of meaning in their lives," Charon said. "That can lead to more comprehensive care."