Medical ethics under managed care.

"Managed Care" is having a profound effect on medical ethics and the patient/physician relationship. Historically, the patient (the first party) contracted with a physician (the second party) to provide medical care. The physician had ethical and legal obligations to the patient. In the "new health care," an employer or the government (the fourth party) or infrequently, the patient (the first party) purchases health care from the HMO, PPO, or similar organization (the third party). The third party then contracts with the physician (the second party) to provide that care. The physician has agreed to two, at times competing and possibly immutably conflicting obligations--one to the patient and one to the third party. The ethical and legal problems that arise from conflict between "the bottom line" and "desired" (appropriate) health care will be difficult to solve. The incompatible duality of physician roles both as patient advocate and manager of limited resources will be further explored, with attention to the enormous pressure being applied to this conflict by society, the law, and the third party. Potential resolutions will be offered. Other ethical problems created by the health care system's conversion to managed care include: CONFIDENTIALITY--Information management is a fundamental underpinning of managed care. With patients switching health care programs frequently, and their enormous size and complexity, careful attention to confidentiality is necessary. INFORMED CONSENT--In addition to informed consent relative to the health care being offered, the patient has a right to know what alternatives might be offered independent of her insurance and payment plan. The patient also has a right to know the economic pressures and arrangements between the second and third parties that could influence the quantity and quality of her health care. QUALITY OF CARE--Managed care contends to be religiously attentive to quality of care. If this is so, the very definition of quality of care may be changing.