REVIEWED BY REV. KEVIN O'ROURKE, OP, JCD, STM
Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics
John La Puma, MD
Hatherleigh Press, New York City
1998, 209 pp., $39.95 (paperback)
"Physicians can practice honorable, first-rate medicine in managed care . . . but they need a new set of ethics and communication and management skills to do it." This is the conviction of John La Puma, a physician who has devoted time and effort to acquire knowledge and skill associated with healthcare ethics.
La Puma is no latecomer to the field of healthcare ethics. He completed a fellowship in clinical ethics at the University of Chicago hospital and founded and directed the Lutheran General Center for Clinical Ethics in Park Ridge, IL. Managed Care Ethics: Essays on the Impact of Managed Care on Traditional Medical Ethics contains short essays originally published in the periodical Managed Care — A Guide for Physicians. In 38 short essays, La Puma describes the "new set of ethics, communication and management skills" that are necessary to practice ethical medicine under the typical managed care system. The work is directed mainly toward physicians, but others engaged in the provision of healthcare, even those in business, as opposed to clinical occupations, will find the considerations interesting and useful.
The clear, challenging writing covers an extensive range of topics. The work considers the main difficulties to which managed care gives rise: confidentiality, quality of care, beneficence, informing patients about the inner workings of the business side of the organization, risk management, and futile care. La Puma insists that ethics in managed care "is not an oxymoron nor a euphemism for toeing the line" but rather a method to uphold the values that matter most to patients, families, and physicians.
Sound and beneficial healthcare ethics requires an objective view of the purpose of human life, a set of core values to help persons achieve this purpose, and a sound method of applying these values to various ethical issues. While these are stimulating and thoughtful essays, I wonder about the core values of managed care and their application. The concern surfaces most forcefully when La Puma considers physician-assisted suicide. While he speaks against it, his values seem to revolve around protecting the reputation of the managed care corporation, rather than around the good of the patient or the moral position of the physician. Thus, after allowing for physician-assisted suicide in one essay (p. 22), he states in the next essay, "Even if physician-assisted suicide were both legally and morally defensible as public policy, it would be the wrong thing for managed care. Why? No one would believe that managed care organizations really wanted to do the right thing. Everyone would think they wanted to do what would not cost much, and what would help them compete in the market." A rose by any other name.
Rev. Kevin D. O'Rourke, OP
Director, Center for Health Care Ethics
Saint Louis University Health Sciences Center
St. Louis