Problems and choices -- Who shall live? -- The physician : the captain of the team -- The hospital : the house of hope -- Drugs : the key to modern medicine -- Paying for medical care.

Though written corporate codes of ethics have been touted as a panacea for the embarrassments and uncertainties of the past two decades, the absence of clear evaluation procedures severely compromises their usefulness. An ethnographic study comparing development processes and compliance outcomes in large health care facilities and energy companies shows that neither of the two industries has encountered much success with a codes of ethics program. Companies that distribute copies of their code of ethics seldom ensure the process is completed (...) or that employees understand the purpose of the document, and staff responsible for the code give it a low priority relative to their overall responsibilities. Contrary to expectations, health care facilities are no more likely to develop or implement codes of ethics effectively than are energy companies. More extensive research is needed in order to generate the data necessary for the development of realistic standards for the evaluation of codes of ethics. (shrink)

Due to society's need to control health care costs and to the failure of legislated health care reform, managed care is expanding at a rapid rate and will soon be the predominate form of health care delivery. Plans by Congress to bring Medicare and Medicaid under managed care will further consolidate this trend. Barring some legislative fiat, managed care is here to stay.The term managed care describes a diverse set of organizational forms. Wide variations in approach, financing, physician involvement, and (...) philosophy exist among the different types of managed care organizations. While many articles on the ethics of managed care acknowledge this variety, most analyses focus on the for-profit entities, paying less attention to the ethical distinctions among the different forms of managed care. This paper discusses the key distinctions among MCO types, in particular the difference between for-profit and non-profit plans; the relationship of the physician to the MCO; the incentives used to control costs; the incentives that improve patient care; and the organizational features that nurture the principled practice of medicine. (shrink)

It is not the outpatient setting, per se, that is presenting new challenges and opportunities to ethics consultants and ethics committees. Rather, it is the underlying reason for shifting more and more patient care from the inpatient to the outpatient setting-namely, calculations of cost-effectiveness.