Values in conflict: neurology before and after the advent of managed care

The transformation of American medicine now taking place is fundamentally driven by money. As the pendulum swings from the excesses of fee-for-service medicine (under which system the physician was paid more for doing more), to the equally egregious excesses of managed care (according to which the physician is paid more for doing less), it is the patient--especially the vulnerable patient with a debilitating neurological disease--who stands to lose the most. A survey of the historical roots of this transformation highlights the ethical dilemmas under the course of the pendulum. The ethical principles that should guide both the profession and the business of medicine are explored in search of a common ground on which both physicians and managers can work in concert for the benefit of the patients as well as the society whom both serve. The perils that beset that search must be recognized and avoided if the commons are to be preserved. This is especially true for neurology, where care must be patient, not profit, oriented; must have quality, not cost, as its primary aim; and must not be rationed until there is a floor of universal coverage, with participation by all in allocation decisions.