The ethics of managed care: challenges to the principles of relationship-centered care

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.