Sabin J E
Harvard Community Health Plan, Boston, MA 02215, USA.
Gen Hosp Psychiatry. 1995 Jul;17(4):293-8. doi: 10.1016/0163-8343(95)00036-q.
Managed care programs come in many stripes, and the field is evolving with bewildering rapidity. In order to be effective advocates and critics, clinicians need a vision of ethical managed care practice, to use as a standard for judgment and quality improvement. This paper presents four principles that I believe capture the essential stance of an ethical clinician in managed care. The central challenge for creating ethical managed care systems is integrating stewardship (communitarian) and fiduciary (patient centered) values. Because general hospital psychiatrists treat individual patients in a "communal" (institutional) setting in which issues of resource use stand out with great clarity, they will play a central role in developing ethical guidelines for managed care practice. This paper considers issues in general hospital psychiatric practice--determining hospital length of stay, deciding how much suicidal risk is tolerable in a treatment plan, and the problems that arise when patients prefer valid but less cost-effective treatments--as examples of the kinds of questions a clinically relevant set of ethics must address.
管理式医疗计划形式多样，且该领域正以惊人的速度不断发展。为了成为有效的倡导者和批评者，临床医生需要具备合乎伦理的管理式医疗实践愿景，以此作为判断和质量改进的标准。本文提出了四条原则，我认为这些原则抓住了管理式医疗中合乎伦理的临床医生的基本立场。创建合乎伦理的管理式医疗系统的核心挑战在于整合管理（社群主义）和信托（以患者为中心）价值观。由于综合医院的精神科医生在“公共”（机构）环境中治疗个体患者，在这种环境中资源使用问题非常突出，他们将在制定管理式医疗实践的伦理准则方面发挥核心作用。本文将综合医院精神科实践中的问题——确定住院时间、决定治疗计划中可容忍的自杀风险程度，以及当患者倾向于选择有效但成本效益较低的治疗方法时出现的问题——作为一系列临床相关伦理必须解决的问题的示例。
