The quality of medical care: a concept in search of a definition.

Patient care has two components: technical and interpersonal. The quality of technical management depends on the balance of its expected benefits and risks. The quality of the interpersonal process consists in conformity to legitimate patient expectations and to social and professional norms. Since this conformity is expected to result in social and personal benefit, a unified definition of quality can be derived by including the benefits and risks of both aspects of care. When the patient's health and welfare are judged by professional criteria, and the cost of care is not considered, one has an "absolutist" definition of quality. By contrast, an "individualized" definition accepts the informed patient's valuation of the consequences of care, and includes the cost to the patient as an unwanted consequence. The "social" definition includes monetary cost even when not borne directly by the patient, may place a different valuation on patients and their interests, and pays attention to the social distribution of the cost and net benefits of care. Thus, the physician who wishes to do the best for each patient may be in conflict with what society dictates to be the best of all. The health care professions must resolve this moral dilemma.