Buchanan A
University of Arizona-Tucson, USA.
J Health Polit Policy Law. 1998 Aug;23(4):617-34. doi: 10.1215/03616878-23-4-617.
Three ethical criticisms of managed care are often voiced: (1) by "skimming the cream" of the patient population, managed care organizations fail to discharge their obligations to improve access, or at least, to not worsen it; (2) managed care organizations engage in rationing, thereby depriving patients of care to which they are entitled; and (3) by pressuring physicians to ration care, managed care organizations interfere with physicians' fulfillment of their fiduciary obligations to provide the best care for each patient. This article argues that each of these criticisms is misconceived. The first rests on the false assumption that the health care system includes a workable division of responsibility regarding access that assigns obligations concerning access to managed care organizations. The second and third criticisms wrongly assume that we in the United States have taken the first step toward assuring equitable access to care for all, articulating a standard for what counts as an "adequate level of care" to which all are entitled. These three misguided criticisms obscure the most fundamental ethical flaw of managed care: the fact that it operates in an institutional setting within which no connection can be made between the activity of rationing and the basic requirements of justice.
（1）通过挑选患者群体中的“优质客户”，管理式医疗组织未能履行其改善医疗服务可及性的义务，或者至少没有使其恶化；（2）管理式医疗组织进行医疗资源配给，从而剥夺了患者应得的医疗服务；（3）通过向医生施压以进行医疗资源配给，管理式医疗组织干扰了医生履行其为每位患者提供最佳医疗服务的信托义务。本文认为，这些批评中的每一种都是错误的。第一种批评基于一个错误的假设，即医疗保健系统包括一个关于医疗服务可及性的可行责任划分，将有关医疗服务可及性的义务分配给管理式医疗组织。第二种和第三种批评错误地假定，我们美国已经朝着确保所有人公平获得医疗服务迈出了第一步，明确了一个“适当医疗水平”的标准，所有人都有权享有。这三种错误的批评掩盖了管理式医疗最根本的伦理缺陷：即它在一种制度环境中运作，在这种环境下，医疗资源配给活动与正义的基本要求之间无法建立联系。
