Introduction

Dr. Douglas Diekema has set forth a series of cases illustrating ethical concerns that arise for pediatricians practicing medicine in managed care settings. This chapter explores how the environments of managed care alter the physician's ethical role as patient advocate. The approach to this topic will be twofold. I begin by exploring rationing within managed care organizations (MCOs), using the cases set forth in the previous chapter to illustrate distinct rationing methods and criteria. Then I identify the limits these forms of rationing impose on patient advocacy, with an eye to clarifying the pediatrician's ethical role in healthcare rationing.

Possible methods of rationing within MCOs

Rationing occurs whenever physicians, hospitals, MCOs, purchasers, or others deny beneficial health care to patients under conditions of scarcity. But what is scarcity? In some instances, the raw materials from which healthcare services are made are themselves limited and there is not enough to provide them to everyone who stands to benefit. This first kind of scarcity is referred to as “resource scarcity” to emphasize the finite nature of the resources required to produce healthcare services (Morreim 1995). One example of resource scarcity is organ transplantation. The supply of hearts, lungs, kidneys, and other organs required for transplantation is currently insufficient to meet demand. Another example of resource scarcity is specialty care. In rural areas of the United States, medical specialists may be unavailable to patients who need them.