Quality of neurological care. Balancing cost control and ethics

As the quality of neurological care becomes a mutual objective of physicians, patients, and health planners, increased demands on cost savings will create conflicts that could threaten the ethical basis of medical practice. Physicians will see increasing ethical conflicts between their fiduciary duties to make treatment decisions in the best interest of their patients and their justice-based duties to conserve societal resources. These conflicts can be best mitigated if physicians maintain their orientation as patient advocates but practice cost-conscious clinical behaviors that consider the cost-effectiveness of tests and treatments and do not squander society's finite resources by ordering medical tests and treatments of zero or marginal utility. Health system planners should resolve their conflicting objectives of quality and cost control by rigorously defining and measuring quality through physician leadership and by implementing cost-control measures that enhance the quality of medical care. Managed care organizations voluntarily should forsake financially successful but blatantly unethical cost-saving schemes, such as gag clauses and end-of-year kickback payments to physicians, because these schemes diminish patients' trust in physicians and degrade the integrity of the patient-physician relationship. State and federal laws should prudently regulate these unethical cost-saving schemes to the same extent as they have for the harmful conflicts in fee-for-service medicine.