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Balancing Act: The New Medical Ethics of Medicine's New Economics.

Professor Morreim's mission in this highly readable, well-referenced volume is to convince us that we must "bid farewell to the insular, dyadic relationship between physician and patient" in favor of a more community-based vision of health care. Others have shared this vision, notably Daniel Callahan, but Morreim provides a more detailed analysis of the practical implications of the proposed paradigm than previously attempted. She concludes that a policy wherein physicians split their loyalties between patients and society is both ethically and practically tenable.

Morreim argues that we must accept--as we have not yet explicitly done--different standards of care for different patients, covered by various levels of health insurance. That is, similar patients would legitimately be treated differently based on their insurance coverage, with more extensively insured patients receiving more potentially beneficial services. This idea, though still controversial, is not fundamentally different from the President's Commission conclusion to the effect that an "adequate level of care" for all can ethically be supplemented by higher levels of care for those who desire and can afford it. Like the President's Commission, Morreim sidesteps the "challenging question" of how these different levels of care might be defined in practice.

The author analyzes a host of issues that arise from her call to physicians to abandon their tradition of unequivocal advocacy. The issues include whether and when physicians should inform patients about existing but uncovered services, problems of financial conflicts of interest, and the appropriateness of physicians' "gaming" the system. Morreim devotes several very thoughtful pages to this latter issue, concluding that gaming is ethically untenable and tantamount to "revolutionary civil disobedience."

Professor Morreim acknowledges, but seems ambivalent about, the central role that clinical guidelines must surely play in balancing physician and patient autonomy against fiscal constraints. Although, as she acknowledges, physicians can retain their pure advocacy role by following clinical guidelines, Morreim argues that physicians may thereby "escape saying no [only] by becoming impotent to say yes."

"In the end," Morreim concedes, "physicians cannot avoid and generally should not resist increased standardization of care." Even so, she continues, guidelines "must still leave flexibility for individuality of care... [and for] important personal differences." [his tension gets to the heart of the issue. Morreim argues that guidelines should standardize care but still leave physicians adequate wiggle room. This will work, as she observes, only if physicians resist the temptation to exploit inevitable guidelines vagaries and loopholes on behalf of their patients--even when there is some palpable chance that those patients would benefit from such exploitation. As a guiding principle, Morreim offers a variation on Kant's categorical imperative: physicians should take advantage of guideline loopholes only when they would want to see all other physicians in similar situations do the same.

This prescription does indeed constitute a difficult "balancing act," one that I am not sure can be successfully negotiated within modern American society. This element of doubt not-withstanding, Balancing Act is filled with enlightening observations and challenging arguments.
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Author:Hadorn, David C.
Publication:The Hastings Center Report
Article Type:Book Review
Date:Nov 1, 1992
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