The patient as commodity: managed care and the question of ethics

Managed care has come to the fore in the medical landscape with such rapidity, vigor, and nearly evangelical zeal that startled witnesses to the transformation have reacted with awe and outrage. In this article we will take a sober look at the system that has in some markets all but consumed the fee-for-service relationships that characterized healthcare just five years ago and dominated the last failed debate on healthcare reform. We will look at selected arguments for and against the justice of such a system, raise pertinent ethical concerns about managed care, and suggest some normative guidelines that a society ought to develop as a way of regulating the medical commons. In the emerging debate about ethical conflicts in the rapidly developing market of managed healthcare, it is critical to remember that all care that is given to patients is managed by someone. The need for management is a function of how healthcare delivery is organized--relying on the intervention of a host of strangers, and, to some extent, the cooperation of a large industrialized state. Strangers must agree on the parameters of care that will address any given expressed need. Even the embodied experience of the patient is named, defined, and categorized not by the patient, but by a stranger, who then, by evaluating the patient's pain, treatment, and outcome, becomes part of the management and narrative of the case. Who owns the instruments, regulates the drugs, and pays the fees will be a critical factor in who sets the parameters and limits in healthcare. What makes the reality of management a subject of ethical discourse is the issue of power, the problem of the marketplace relationships that exist simultaneously, and the norms that ought to guide stranger-to-stranger interaction in a just social order.