Managed care: rationing without justice, but not unjustly.

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.