Thomasma D C
J Allied Health. 1996 Summer;25(3):233-46.
Health care reform involves ethical issues on many levels. First, the impetus to reform the health care system stems in large part from concerns about equity, just distribution of goods and services, and commitments to one another in society. Health care itself is more than a commodity, it is a personal healing activity carried out through institutions that embody values such as respect for persons, the value of human life, and duties to care for individuals who suffer. These issues fall under major overarching concerns on the macro level. Reform, however, often functions as a euphemism for changing the health care system to provide greater profitability, and for controlling costs. Admittedly, such changes can be disguised under reforming the health care system, and indeed, some of them are capable of enhancing and simultaneously making more efficient, our care for one another when sick. Most changes, nonetheless, are clearly driven from less noble ideals. Every schema for providing care also embodies values since these schemas presuppose various competing notions of justice and equity. Further, they may endanger long-held values of health care providers in meeting the needs of patients. As part of state or local-level changes in the health care system, issues in this category can be called micro level concerns. when all the changes impact on individuals, either providers of care, or the patients themselves, then the issues are of concern on the personal level. This essay, therefore, examines ethical issues presented by managed care networks on the macro, micro, and individual level, with special attention paid to the health care relationship. The subtitle of the essay points out the focus of the discussion on the impact of these changes for more traditional models of relationship-centered care.1 In particular, the essay concentrates on health providers, including allied health professionals, that in the past were grouped into the category of primary care givers but ought to be called first-level care givers today.
医疗保健改革涉及诸多层面的伦理问题。首先，改革医疗保健系统的动力在很大程度上源于对公平、商品和服务的公正分配以及社会成员间相互承诺的关注。医疗保健本身不仅仅是一种商品，它是一种通过体现诸如尊重个人、人类生命价值以及照顾受苦个体的责任等价值观的机构来开展的个人治疗活动。这些问题属于宏观层面的主要总体关切。然而，改革往往是改变医疗保健系统以获取更大利润和控制成本的委婉说法。诚然，此类变革可能被伪装成医疗保健系统改革，而且实际上，其中一些变革能够在我们生病时增进并同时提高我们相互照顾的效率。尽管如此，大多数变革显然是由不太高尚的理念驱动的。每种提供护理的模式也都体现着价值观，因为这些模式预设了各种相互竞争的正义和平等观念。此外，它们可能危及医疗保健提供者在满足患者需求时长期秉持的价值观。作为医疗保健系统在州或地方层面变革的一部分，这一类别的问题可被称为微观层面的关切。当所有变革影响到个人，无论是护理提供者还是患者自身时，那么这些问题就是个人层面所关切的。因此，本文将探讨管理式医疗网络在宏观、微观和个人层面所呈现的伦理问题，特别关注医疗保健关系，并将重点放在这些变革对更传统的以关系为中心的护理模式的影响上。1 尤其，本文将集中讨论医疗保健提供者，包括辅助医疗专业人员，他们过去被归类为初级护理提供者，但如今应被称为一级护理提供者。
