Bioethics, clinical ethics, and professional ethics are mature, well-developed fields of applied ethics that focus on medical research, patient autonomy and patient care, patient–healthcare professional relationships, and issues that arise in clinical and other medical settings. However, despite these developments, little attention has been paid to the organizational aspects of healthcare in these fields. This is surprising, because in the last 30 years healthcare has become more and more institutionalized in provider, management, and insurer organizations. Despite JCAHO's preoccupation with organizational ethics during the last decade, the philosophical underpinnings of their requirements have been less explored in the literature. Clinical ethics remains preoccupied with clinical patient care and professional ethics with individual professional guidelines; even the American College of Healthcare Executives focuses primarily on healthcare managers, not on healthcare organizations.

Suppose a “blue sky” meeting had been called among chief medical officers, chief administrative officers, and other leaders from a range of health-related institutions in this country. The question posed for this meeting was simple but unusual: Are the structures of our organizations, systems, and institutions ethical? Though it was a question reminiscent for a few of the focus some time before on whether the conduct of individuals in their organization was ethical, this question seemed more demanding. Is it reasonable to consider structures or arrangements as ethical or not; or in other words, is ethics an applicable attribute of organizations? And if it is reasonable to speak of an ethics of organizations, by what method might one discern any kind of an answer? And what of the informal connections that link different organizations … how can they be evaluated?

Until recently (before managed care), business issues in healthcare organizations (HCOs) were relatively insulated from clinical issues, for several reasons. The hospital at earlier stages of its development operated on a combination of charitable and equitable premises, allowing for providing care to be separated from financial support. Physicians, who were primarily responsible for clinical care, constituted an independent power nexus within the hospital and were governed by their own professional codes of ethics. In exchange for a great deal of control over their conditions of practice, they took almost complete responsibility for patient care. Thus clinical and professional ethics could to some extent be compartmentalized from the business issues—a much easier feat when, as in much of the last few decades, virtually all care was reimbursed from some source or other. In addition, many HCOs were not categorized or treated as businesses, although of course they were presumed to be governed by the same expectation for good management as any other organization.

The Clinton administration's revised rules regulating but not prohibiting the common practice in managed care of linking physician compensation with cost cutting and control of services demonstrates the complexity of ethical issues in managed care. As originally proposed, the federal guidelines on payment for Medicare and Medicaid services would have precluded any interrelationship between payment to physicians and delivery of services. Such a restriction would have gutted the primary mechanism in managed care plans to curb the unacceptably high cost of healthcare delivery: making physicians directly responsible for cost control by placing them at direct financial risk. At first blush such a linkage seems to involve an obvious and irreconcilable conflict of interest. How can a physician be responsible for the well-being of a patient while at the same time aware that a proportion of his or her income is linked to the provision of cost-conscious care?

The bioethics literature on managed care has devoted significant attention to a broad range of conflicts that managed care is perceived to have introduced into the practice of medicine. In the first part of this paper we discuss three kinds of conflict of interest: conflicts of economic incentives, conflicts with patient and physician autonomy, and conflicts with the fiduciary character of the physician–patient relationship. We argue that the conflicts are either not as serious as they are often alleged to be or not unique to managed care. In part two we argue that managed care represents a new paradigm for medical care that features a new concept of management. We discuss three types or levels of management that managed care highlights, namely, administrative, clinical, and resource, which together offer a more sophisticated vantage point from which to assess patient care. We do not endorse managed care, but attempt to highlight some of the positive changes brought by managed care that were difficult to attain under traditional reimbursement systems.

Medicine needs our trust. We need to be able to rely on individual clinicians and researchers, and we need to be able to have confidence in hospitals and clinics. Yet the organization of our healthcare institutions is not designed to promote that trust. In fact, the structure of our medical institutions seems to undermine our faith.

Max Weber, the grandfather of organizational theory, recognized the close association between health care organizations and law. When he introduced the concept of a legal–rational bureaucracy, he used hospitals and clinics to illustrate it. Today, there is little doubt that healthcare organizations are “law-saturated,” if not always fully compliant with the law. Like Weber's legal–rational bureaucracies, healthcare organizations have highly formalized rules and procedures. They pay a great deal of attention to legal criteria in decisionmaking, and some have entire departments devoted to legal risk management.

Hospital ethics committees have evolved as a response to complicated legal, ethical, and social dilemmas that accompany modern medicine. In the United States, their growth has been augmented by Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) standards and the Patient Self-Determination Act. There appears to be an implicit presumption that all clinical ethics consultation practices are relatively similar. Finally, there is heightened awareness of the needs for quality standards and assessment of the outcomes of ethics consultations.

These CQ Sources were compiled by Bette Anton, Edward M. Spencer, Ann E. Mills, and Carlton Hegwood Jr.

Robert Nozick, in what is surely one of the most intriguing and provocative footnotes in modern philosophical writing, referred in Anarchy, State and Utopia to the notion of a “genetic supermarket.” In keeping with the central arguments of that text, his suggestion was that choices about the genetic composition of future generations should, as far as possible, be left in the hands of private individuals, and should not be determined or restricted by the state. This free market in genetic screening would meet “the individual specifications (within certain moral limits) of prospective parents,” and would possess “the great virtue that it involves no centralized decision fixing the future human type(s).” In short, prospective parents would be allowed, to whatever extent was rendered possible by current technology, to choose the genetic traits of their future children.

Fifty years ago, 23 Nazi physicians were defendants before a military tribunal in Nuremberg, charged with crimes against humanity. During that trial, the world learned of their personal roles in human experimentation with political and military prisoners, mass eugenic sterilizations, state-ordered euthanasia of the “unfit,” and the program of genocide we now know as the Holocaust. These physicians, and their colleagues who did not stand trial, were universally condemned in the free world as ethical pariahs. The term “Nazi doctor” became the paradigm for total defection from the most rudimentary elements of medical morality. The caduceus literally became the instrument of the swastika.

The critique of the United Network for Organ Sharing (UNOS) liver allocation policy by Kenneth Himma has flaws related to the complexities and evolutionary nature of the field. Recent improvements in transplantation have achieved national attention of this sort. There has been an evolution, unequaled elsewhere in medicine, of a national data set and national rules. The transplant community might have been more effective in communicating the details of this, and the problems associated with organ allocation policy. The novelty and complexity of the new rules understandably can produce misleading conclusions.

In “A Critique of UNOS Liver Allocation Policy,” I argued that the UNOS policy of placing acute liver failure patients (ALF patients) above chronic liver failure patients (CLF patients) on the transplant list fails to satisfy the principles of utility and justice that ostensibly guide UNOS allocation policy. Further, I argued that physician discretion in evaluating ALF and CLF patients should be expanded—not constrained. In response, Dr. Burdick attempts to justify the policy constraints on physician discretion on the strength of objective differences between ALF and CLF; as he puts it, “the distinction between acute liver failure and progression of chronic liver disease … is clear in the way brain death is.”

There is good news, and there is bad news. The good news is that in my experience, younger physicians generally are much more concerned about the cost of clinical tests and treatments, and about justly distributing finite medical resources, than were those who practiced medicine in the fee-for-service era. The bad news has at least three components. First, with respect to medically nonbeneficial treatment in the ICU, managed care has not yet given evidence of wanting to put the brakes on unrealistic family demands for aggressive medical interventions. Second, managed care is frustrating many healthcare professionals as well as patients. And third, managed care has no apparent interest in addressing, and may even have contributed to, the problem of medical indigence. Let me develop these propositions more fully.

George Annas serves a critical function as an incisive commentator on the interactions between law and medicine and law and public health. Along with Alex Capron, Dena Davis, Rebecca Dresser, and Larry Gostin—to pinpoint a few—Professor Annas analyses legal aspects of a spectrum of medicolegal issues both in a forum and in a manner that makes them accessible and understandable to a broad community of healthcare providers. His latest book, Some Choice, continues that valuable tradition. The bulk of the volume (17 out of 22 chapters) is drawn from essays originally published as the “Legal Issues in Medicine” feature of the New England Journal of Medicine. The topics include such staples of patients' rights debate as the boundaries of informed consent, authorization of medical experiments, and physician-assisted suicide. A treat is the inclusion of less frequently covered issues, such as access to health information concerning presidential candidates and constitutional bounds of limits on cigarette advertising.

Classical American pragmatists, such as William James, John Dewey, and C. S. Peirce, have had little influence on the development of bioethics. Glenn McGee and the other authors whose essays make up this book believe that this is a mistake. They maintain that the work of these pragmatists constitutes an original and effective method for understanding and resolving bioethical dilemmas. Their collective goal is to convince the rest of us that they are right.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.