Ethical Considerations in Disease Management: A Managed Care Perspective

Managed care, with its restrictions on patient and provider autonomy, has dominated the delivery of healthcare in the US over the last decade. The latest model of managed care has focused on disease management programs, which outline optimal cost-effective processes for care, built on evidence-based guidelines. Patients and providers seem to be more accepting of these programs than of the restrictive managed care practices, but ethical dilemmas remain for both patients and providers when participating in such programs. The basic ethical tenets of beneficence (to do good), autonomy (to make one\u27s own decisions) and non-maleficence (to do no harm), have been well accepted by the medical community. Under managed care these basic tenets have been challenged, with a notable impact on the principle of autonomy; patients lose their choices in selecting care providers, while healthcare providers face restrictions on what pharmaceutical agents they can prescribe and how to care for patients. Additionally, the changing nature of managing care has highlighted conflicts of interest between: patients and the providers of healthcare; patients and the implementers of health plans; and providers and health plans. Conflicts of interest between various parties involved in healthcare challenge the fundamentals of ethical principles, particularly autonomy and beneficence. Recently, there has been greater recognition of the ethical notion of social justice (including the competing concepts of distributive and contributive justice), in terms of the provision of healthcare, partly due to the development of concerns over the expense of, and access to, healthcare. Distributive justice reflects the broader societal concerns over the provision of scarce resources for all citizens, and argues for universal coverage schemes. The concept of contributive justice recognizes that principles of equity demand that we allocate commonly collective funds fairly to those who have contributed to the pool of funds; in the realm of healthcare in the US this is particularly relevant for those who have insurance coverage. Disease management programs offer great potential to improve healthcare. Programs that are developed with attention paid to the principles of beneficence and social justice as well as to concerns regarding patient and provider autonomy can limit conflicts of self-interest