Trusting Medicine: The Moral Costs of Managed Care

195 Pages·2005·20.005 MB·English

by  Patricia Illingworth

Trusting Medicine

Trusting Medicine
The Moral Costs of Managed Care
Patricia Illingworth, J.D., Ph.D.
~~ ~~~~~;n~~~up
LONDON AND NEW YORK
First published in 2005 by Routledge
2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
Simultaneously published in the USA and Canada
By Routledge
270 Madison Avenue, New York, NY 10016, USA
Routledge is an imprint of the Taylor & Francis Group
Transferred to Digital Printing 2006
© 2005 Patricia Illingworth
Typeset in 10/12 Sabon by J&L Composition, Filey, North Yorkshire
All rights reserved. No part of this book may be reprinted or
reproduced or utilized in any form or by any electronic, mechanical,
or other means, now known or hereafter invented, including
photocopying and recording, or in any information storage or
retrieval systems, without permission in writing from the publishers.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloguing in Publication Data
A catalogue record has been requested
ISBN 0-415-36482-5 (hbk)
ISBN 0-415-36483-3 (pbk)
Publisher's Note
The publisher has gone to great lengths to ensure the quality of this reprint
but points out that some imperfections in the original may be apparent
For my daughter Zoe with so much love.

Contents
Acknowledgements
lX
Introduction 1
An overview of this book 6
Defining managed care 9
1 Conflicting values in a troubled health-care system 13
The cost of care 15
Ethical assumptions, principles and theories 18
Stewardship, social justice and contributive justice 21
2 Bluffing, puffing, and spinning 30
Bluffing and the warranty theory of truth 32
Deception within health plans 34
Physician deception 36
Deception through silence: debating disclosure 3 8
Warranting the truth 41
Patient deception: damned if they do, damned if
they don't 43
Assumption of the risk 46
3 Trust: the scarcest of medical resources 52
Trust 54
The doctor-patient relationship: a vessel of trust 58
Medical trust at risk 60
Coping with the problem of declining trust between
doctor and patient 62
Trust as procedural justice 62
vm Contents
Fragility of trust 67
Costs of conserving trust 70
4 The doctor-patient relationship in a social context 77
Social relations are important for health promotion 80
The impact of income inequality on health 84
Managed care and the erosion of the professional
practice standard 85
The myth of choice 87
5 Conserving medical trust for the sake of social capital 92
Trust and social capital 95
The consequences of diminishing social capital for individuals 97
Harms to the community from our depleted fund of
social capital 98
Implications for the consent argument 100
Protecting our reservoir of medical trust 101
Trading trust 1 03
6 Law, its meaning, and its effect on social capital 107
Expressive theories of law 109
ERISA: a window of opportunity 11 0
Pegram v. Herdrich 111
Expressive content and social capital 113
The professional practice standard 120
Thinking about policy implications 123
7 Employer leadership in the era of workplace rationing 127
Starting with clinical ethics 129
Employers cum proxy decision-makers 130
Implementing substituted judgment 134
Best-interest-of-the-employee test 13 7
Employer cost shifting and the failure to meet
proxy criteria 13 7
Employer leadership in exercising discretion 141
The argument from social capital 142
8 Protecting medical trust, conserving social capital 150
Bibliography 161
Index 179
Acknowledgements
This book focuses on the doctor-patient relationship and the role it plays
in the health and welfare of the community. Many people have helped with
this book both directly as researchers and readers and indirectly, by pro-
viding support and encouragement to me. I benefitted enormously from the
comments, conversations, and suggestions of Regis de Silva, John Field,
Leonard Fleck, Thomas Gutheil, Robert Hamm, Michael Hendryx, Tim
Murphy, Udo Schuklenk, James Sabin, Alan Stone, Paul Ward, and Dan
Wikler. I am grateful to each of them. Wendy Parmet and Margaret
Somerville gave the last draft of the book a very careful reading. Their
extensive comments and friendship throughout the long process of writing
this book are deeply appreciated.
Much of this book was written while I was an Ethics Fellow in the
Division of Medical Ethics at Harvard Medical School. I thank both
Northeastern University for a much-needed sabbatical and the Division of
Medical Ethics for providing me with a collegial atmosphere in which to
write it. Walter Robinson ran a wonderful seminar, an intellectually rich
and engaging forum, in which to think about what it is to do bioethics and
to develop a research project. I am extremely grateful to him and seminar
members, all of whom provided me with excellent comments on an early
draft of this book. I also learned a great deal from the faculty seminar con-
ducted by Marcia Angell and thank her for the thoughtfulness she brought
to the seminar. I have also benefitted enormously from conversations with
members of the Program in Psychiatry and the Law at Harvard Medical
School. I thank them for always welcoming me to the program.
I have been blessed with many good friends who have supported me with
their kindness, laughter, curiosity and patience throughout the process of
writing this book. Although there are many friends and family members who
deserve mention, I am limited to naming only a few and am particularly
grateful to Claire Aldrich, Harold Burzstajn, Jillian Clare-Cohen, Nancy
Dearman, Dean Gilmour, Crystal Greene, Russell, Judy and Suzanne Higley,
Joan Illingworth, Martin Illingworth, Charlotte Ikels, Erika Jungblut,
John Kotter, Claude Menders, Joanne Cipolla Moore, Johnathon Palmer,