The Ethics of Cost-Containment: Bureaucratic Medicine and the Doctor as Patient-Advocate
Notre Dame Journal of Law, Ethics & Public Policy
Volume 3
Issue 2 Symposium on Medical Cost Containment Article 3
1-1-2012
The Ethics of Cost-Containment: Bureaucratic
Medicine and the Doctor as Patient-Advocate
Ba
y R. Fu
ow
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[email protected]THE ETHICS OF COST-CONTAINMENT:
BUREAUCRATIC MEDICINE AND THE DOCTOR AS
PATIENT-ADVOCATE
BARRY R. FURROW*
INTRODUCTION
Physicians are feeling the heat of cost containment. Pres-
sures on doctors to contain costs have mounted - from hos-
pital and Health Maintenance Organization (HMO) adminis-
trators, from state and national government, from medical
staffs. Medicare payment reforms, corporate and insurer de-
mands, and market pressures have all come together to pres-
sure health care providers to cap escalating health care costs.
This article posits that such pressures to control costs are not
always counter to the patient's best interests and that the eth-
ical debate needs to incorporate the emergence of bureau-
cratic medicine and its sensitivity to cost.' The pressure to
educe cost has intensified the tension felt by physicians as
they balance their ethical obligations to treat their patients
and their desires to maintain the financial health of thei
health care institutions and their own financial security. The
line between pure medical decisions and economic decisions
has blu
ed.' The essence of the complaint is simply stated:
"... economic imperatives may weaken what should be a
strong fiduciary relationship between doctor and patient. A
physician cannot easily service his patients as trusted coun-
selor and agent when he has economic ties to profit-seeking
usinesses that regard those patients as customers." 3
* Professor of Law, Delaware Law School, Widener University. B.A.,
Harvard College, 1967; J.D., Harvard Law School, 1971.
1. For an excellent discussion of incentives and various ways of pay-
ing physicians, see Capron, Containing Health Care Costs: Ethical and Legal
Implications of Changes in the Methods of Paying Physicians, 36 CASE W. RES. L.
REV. 708 (1986).
2. P. STARR, THE SOCIAL TRANSFORMATION OF AMERICAN MEDICINE 447
(1982); V. FUCHS, WHO SHALL LIVE?: HEALTH, ECONOMICS, AND SOCIAL
CHOICE 145 (1974). See generally V. FUCHS, THE HEALTH ECONOMY (1986).
3. Relman, Practicing Medicine in the New Business Climate, 316 NEW
ENG. J. MED. 1150, 1150 (1987). These "economic imperatives" can in-
clude not only profit-sharing a
angements, but also membership in HMOs
and employment in health care institutions, both profit and nonprofit, that
use a variety of financial incentives to control costs. See Weissburg & Stern,
JOURNAL OF LAW, ETHICS & PUBLIC POLICY
The cu
ent ethical debate seems to revolve primarily
around middle class medicine, where physician autonomy in
treating patients has been most dramatically limited by new
modes of health care delivery and reimbursement. Prospec-
tive payment mechanisms have been implemented through
the federal Medicare program, but hospitals have applied
DRG categories across the board to their delivery of health
care. As hospitals struggle to contain costs, they have imple-
mented cost controls that affect a doctor's practice generally
and not just that segment involving Medicare patients."
Can Hospitals Reward Physicians for Reducing Unnecessary Utilization?, FED.
AM. Hosp. REV. 45 (Sept. - Oct. 1985). The authors note that "[s]ome sys-
tems are so complex that they utilize sophisticated computer programs
which analyze past performance and the severity of illness of individual pa-
tients, while others merely reward a physician if the hospital's costs for a
specific patient are less than the DRG payment." See also Mo
eim, The MD
and the DRG, 15 HASTINGS CENTER REP. 30 (June 1985).
4. Those treating the poor have always been aware of the rationing
aspects of the process. See generally Rosenblatt, Medicaid Primary Care Case
Management, the Doctor-Patient Relationship, and the Politics of Privatization,
36 CASE W. RES. L. REV. 915 (1986), particularly at 917-18 and accompany-
ing notes. Much of the problem discussed here does not address the real
"emergency" delivery of health care to under or uninsured patients, o
Medicaid patients. For whole classes of our population, the rationing di-
lemma experienced by the doctor is far more of a vise grip than a gentle
squeeze. The population affected thus makes a large difference to the ethi-
cal debate. With the poor, the level of scrutiny is at the political level, a
macroallocation question as to inadequacy of resources available as a pool
for the poor group. Schroeder, Strategies for Reducing Medical Costs by
Changing Physicians' Behavior: Efficacy and Impact on Quality of Care, 3 INT'L
J. TECH. ASSESS. IN HEALTH CARE 39, 47 (1987). "Whether attempts to re-
duce medical costs by changing physicians' behavior will harm patient care
depends upon the population affected and the services withheld. If the bur-
den of cost containment falls upon those who already have poor access to
care, then the quality of care will surely fall." Id. at 48. He concludes:
". .. how cost-containment measures affect the quality of care depends
upon their type and efficacy, the prevalence of unnecessary care, and the
vulnerability of the patients whose clinical services would be reduced, and
the type of services withheld." Id. See also Dallek, Commentary, 36 CASE W.
RES. L. REV. 969 (1986).
Physicians serving the poor make more of the tradeoffs discussed here
than do those doctors who treat the middle class in HMOs or hospitals.
This article addresses the debate at the level of middle class medicine,
while conceding that the harder issues are raised by the scarce resource
problems involved in treatment of the poor.
Berenson has written that "it has not been unusual for me . . . to have
to negotiate with Medicare patients over my recommended drug regimens
in order to accommodate patients' very real budgetary constraints." Beren-
son, A Physician's Perspective on Case Management, 2 Bus. & HEALTH 22, 22-
23 (1985).
[Vol. 3
THE ETHICS OF COST-CONTAINMENT
I. OVERVIEW OF METHODS TO REDUCE MEDICAL COSTS
In 1982 Congress approved prospective reimbursement
of hospitals on a diagnosis-related groups (DRGs) basis fo
Medicare.5 This system was designed to provide incentives
for cost containment by creating an administered price sys-
tem under which hospitals are paid a predetermined price fo
services based upon an average cost calculation for a patient
with a particular diagnosis. This replaced the previous fee-
for-service system under which the hospital billed the federal
government for the actual charges incu
ed and was paid
with little risk of challenge. Medicare's new system covers
hospital care for Medicare patients in every state except New
Jersey, Maryland, New York, and Massachusetts.6 Some pri-
vate insurers have also adopted some version of it as well to
control their reimbursement costs.
Financial institutional a
angements in hospitals also seek
to control and channel physician behavior in cost-saving di-
ections. Such "cost constraints" are "a source of pressure
upon clinical decisionmaking through hospital rules or moni-
toring systems which tie physician salary, staff privileges, o
other benefits to effective control of costs."' The evidence
suggests that the most effective mode of changing medical
practice is the alteration of the financial incentives that affect
physicians. That is precisely the goal of incentive systems and
institutional designs, such as HMOs. Strategies for altering
physician behavior have ranged from education, feedback,
egulatory approaches such as Certificates of Need (CON),
insurance coverages, to financial incentives, either within hos-
pitals or inherent in structural forms such as HMOs.'
A. Ethical Dilemmas Posed by Cost Containment
The ethical tensions confronting the physician in an era
of cost-containment are complex. The conflicts experienced
y the physician may vary in intensity, depending upon the
source of cost pressures and the nature of the institution.
5. See Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. No.
97-248, s.101, 96 Stat. 324, 331 (1982) (codified as amended at 26 U.S.C.
§ 1 (1986)).
6. 50 Fed. Reg. 24,366, 24,446 (1985). These four states have re-
ceived waivers under 42 U.S.C. § 1395 (1986) to operate their own cost
control systems under Medicare.
7. Fu
ow, Medical Malpractice and Cost Containment: Tightening the
Screws, 36 CASE W. RES. L. REV. 985, 989 (1986).
8. See generally Schroeder, supra note 4, at 45.
19881
JOURNAL OF LAW, ETHICS & PUBLIC POLICY
The range of financial incentive schemes is quite extensive.
Thus, prospective payment schemes such as the Medicare
DRG system do not order the doctor or the hospital not to
treat or hospitalize a patient. Rather the message is that the
provider can do what it wants, but will only get paid whateve
the categories allow. Given the need to balance a budget, in-
stitutional incentives to follow the payment categories are
strong.
Incentive systems in some institutions tie physician per-
formance to level of utilization in a variety of ways. Capita-
tion systems such as HMOs put physicians at risk by conscious
design. The capitation principle means that payment is deter-
mined in advance for each subscriber to the HMO, and the
HMO will lose money if its costs per patient exceed the
amount they have collected. Physician gatekeepers attempt to
discourage overutilization in the HMO; the norms of practice
of physicians in HMOs tend toward lower levels of utilization
generally.10 Staff privileges may be indirectly tied to overu-
tilization as well.1 Physician-owned clinics and other medical
centers likewise provide very direct and strong incentives fo
physicians to practice profitable medicine. Overall, cost con-
siderations have become an integral part of medical
practice.'
2
9. See Fu
ow, supra note 7, at 990.
10. The literature on practice patterns in prepaid group practices
supports the hypothesis that diagnostic and treatment patterns differ from
fee-for-service settings. See Pineault, The Effect of Prepaid Group Practice on
Physicians' Utilization Behavior, 14 MED. CARE 121 (1976); Dorsey, Use of Di-
agnostic Resources in Health Maintenance Organizations and Fee-For-Service
Practice Settings, 143 ARCH. INTERN. MED. 1863 (1983); Hartzema and Chris-
tensen, Nonmedical Factors Associated with the Prescribing Volume Among Fam-
ily Practitioners in an HMO, 21 MED. CARE 990 (1983); Yelin, Henke, &
Kramer, A Comparison of the Treatment of Rheumatoid Arthritis in Health
Maintenance Organizations and Fee-For-Service Practices, 312 NEW ENG. J.
MED. 962 (1985).
11. See Knapp v. Palos Community Hosp., 125 Ill. App. 3d 244, 465
N.E. 2d 554 (1984), where a hospital denied a staff physician's reappoint-
ment. The hospital inquiry concentrated on the doctor's excessive use of
lung scans, medications, tests, pacemakers, and pulmonary angiograms.
The doctor's peers also testified that his excessive testing resulted in 30%
higher costs to the institution.
12. See generally Luft, Economic Incentives and Clinical Decisions, in THE
NEW HEALTH CARE FOR PROFIT: DOCTORS AND HOSPITALS IN A COMPETITIVE
ENVIRONMENT 102 (B. Gray ed. 1983); Egdahl & Taft, Financial Incentives to
Physicians, 315 NEW ENG. J. MED. 59 (1986).
For a discussion of hospital responses to the new competitive environ-
ment, see Waldholz, Most Hospitals Quickly Learn to be Profitable, WALL ST. J.,
Aug. 28, 1985, at 6, col. 1. See also PROSPECTIVE PAYMENT ASSESSMENT COM-
[Vol. 3
THE ETHICS OF COST-CONTAINMENT
Critics of using economic incentives to change physician
ehavior are concerned about the desirability of the end re-
sults of such behavioral changes on health care delivery and
quality of care. Alexander Capron wo
ies, for example, that
exposing physicians to financial risks through incentive sys-
tems and prepaid plans will exace
ate access problems fo
significant percentages of our population that are already un-
derserved. He writes: "Capitation programs, packaging of
services, and prepaid a
angements such as HMOs have a
uilt-in disincentive to accept the sickest and poorest patients,
the very ones who have the hardest time obtaining health
care.""3 Thus, before we implement a variety of incentive sys-
tems and cost constraints, we must be satisfied that the physi-
cian-patient relationship will still function and that patient
care will not suffer as a result.
B. Rationing
The specter of physicians consciously engaged in ration-
ing at the bedside has excited much commentary." Of
course, rationing of a scarce supply of health care resources is
MISSION, MEDICARE PROSPECTIVE PAYMENT AND THE AMERICAN HEALTH CARE
SYSTEM: REPORT TO THE CONGRESS 52 (Feb. 1986).
13. Capron, Containing Health Care Costs: Ethical and Legal Implica-
tions of Changes in the Methods of Paying Physicians, 36 CASE W. RES. L. REV.
708, 752 (1986).
14. See Bayer, Callahan, Fletcher, Hodgson, Jennings, Monees,
Sieverts & Veatch, The Care of the Terminally Ill: Morality and Economics, 309
NEW ENG. J. MED. 1490 (1983); Mo
eim, The MD and the DRG, 15 HAS-
TINGS CENTER REP. 30, 36 (1985). As the reimbursement purse strings have
tightened at all levels, physician awareness of the tradeoffs has become
acute. Fuchs writes:
Increasingly, physicians are being asked to resolve this problem;
that is one reason why the issue of "rationing" takes on a new
urgency. The pressure to be more economical in the provision of
care will force physicians to make decisions that are contrary to
the best interests of individual patients, even though these deci-
sions may make a great deal of sense from the viewpoint of society
as a whole. Moreover, pressure to control costs will raise explicitly
the question of who gets how much care. In the past this question
was often answered implicitly by where the patient lived and
whether he could pay. In the future, in the interest of maintaining
equity while controlling costs, it may be necessary to withhold care
from patients who have ample income or complete insurance and
who therefore believe that they are entitled to "everything
possible."
Fuchs, The 'Rationing' of Medical Care, 311 NEW ENG. J. MED. 1572, 1573
(1984).
19881
JOURNAL OF LAW, ETHICS & PUBLIC POLICY
nothing new. Physicians have always engaged in the rationing
of health care, in the sense of distributing a limited supply.'"
This distribution was usually accomplished implicitly in a va-
iety of ways that concealed or disguised it. The choices that
a rural practitioner might offer her patient would be more
limited in many cases than those available to her u
an coun-
terpart, both because of the lack of medical or institutional
esources, such as high technology diagnostic tools, and be-
cause of the income differentials among patients. Such com-
mon sense rationing has received legal approval in malprac-
tice case law." The ability of the consumer to pay within the
health care marketplace was the dominant mode of rationing
health care as recently as two decades ago, when more than
half of individual health care payments were made directly by
patients.
1 7 -
Second, the geographic location of the patient made a
large difference in the quality of care available, since the acci-
dent of geography meant access to more or less hospital care
of varying quality and to specialists of various kinds. 8 The
inner city thus typically has few doctors, often foreign born,
counte
alanced in some cities ironically with powerful teach-
ing hospitals; the subu
s have physicians in an office prac-
tice; rural areas few practitioners widely scattered. 9
Third, definitions of diseases by physicians and insurers
affect reimbursement for such care. Denial of a treatment as
not "medically necessary" is a direct form of rationing of that
care. Controversies over reimbursement by insurers of psy-
15. See Fuchs, supra note 14.
16. Scarce resource problems are nothing new to medicine; caselaw
in malpractice cases reflects judicial sensitivity to resource variations in
medical practice. In Hall v. Hilbun, 466 So. 2d 856 (Miss. 1985) for exam-
ple, the Mississippi Supreme Court noted the resource limitations exper-
ienced by a small town Mississippi practitioner. Hall followed the general
judicial practice of taking into account the locality, the nature of the health
care facility, and the proximity of specialists and special facilities in evaluat-
ing the medical standard of care. See also Blair v. Eblen, 461 S.W.2d 370
(Ky. 1970); Restatement (Second) of Torts, § 299A, Comment g. ("Allow-
ance must be made also for the type of community in which the actor car-
ies on his practice. A country doctor cannot be expected to have the
equipment, facilities, experience, knowledge or opportunity to obtain it,
afforded him by a large city.")
17. See Fuchs, supra note 14, at 1572.
18. Id.
19. See P. Sta
, supra note 2, at 361-63.
[Vol. 3
THE ETHICS OF COST-CONTAINMENT
chotherapeutic services, sex change operations, or "experi-
mental" therapies have reflected this form of rationing.2"
Fourth, as Victor Fuchs comments, "the amount and
kind of care that physicians provide is still constrained by
how busy they are, what facilities, equipment, and auxiliary
personnel are available, how much training the physicians
have had, and the informal messages that they receive from
peers about what constitutes 'appropriate' care in any partic-
ular situation. ' 2' Rationing is still ubiquitous in the delivery
of health care services, although it may not be recognized o
defined as such in the practice of middle class medicine.
1. Third Party Payment Blunts Rationing Impact.
Intially, the growth of private and governmental third
party payment mechanisms reduced the role of patient in-
come as a rationing device. Beginning in the 1950's, the in-
creasing availability of health insurance through Medicare
and Blue Cross Blue Shield vastly improved middle class ac-
cess to medical care,22 although social values, geographic dif-
ferences, and skill and resource differences of health care
providers still result in significant variation in access to health
care. This emergence of government funded health care in-
surance had removed much of the decisionmaking tension
from both doctor and patient over the past two decades,
since cost did not have to be a factor in most treatment deci-
sions.23 The availability of third-party insurance thus became
the driving force behind the tremendous expansion of health
care expenditures in the United States, since ". . . when a
third party is paying, the patient will want additional care and
the conscientious physician will provide it, even though its
cost to society exceeds the benefit to the patient."2 ' The
prevalence of insurance has allowed access to care by a much
20. When I was in private practice in Boston, representing Blue
Cross and Blue Shield of Massachusetts, the insurer's physician panel con-
sidered within one two year period such issues as the desirability of includ-
ing within a definition of "medical necessity" chemopapain treatment fo
lower back pain and sex change operations. Given the long term cost of
these treatments, a decision not to provide coverage to subscribers of the
plans would make such treatments impossible for a large percentage of
those who desired them.
21. Fuchs, supra note 14, at 1572.
22. Fox, The Consequence of Consensus: American Health Policy in the
Twentieth Century, 64 MILBANK Q. 76, 84 (1986).
23. See Rosenblatt, supra note 4, at 917.
24. Fuchs, supra note 14, at 1572.
19881
JOURNAL OF LAW, ETHICS & PUBLIC POLICY
larger percentage of the public, and has therefore served im-
portant social functions. It has also shielded both patient and
doctor from the need for careful scrutiny of the costs of the
services rendered.25
2. Cost Containment Reasserts Rationing Pressure.
The cu
ent "rationing" problem is now more strongly
felt by physicians in middle class practice because suddenly
ationing is again out in the open, rather than concealed by
structural and geographic differences. The HMO docto
must now examine the necessity for the more expensive third
generation antibiotic rather than the cheaper ones available;
he must weigh the need for extended hospitalization of a pa-
tient. As hospitals try to reduce the volume of costly diagnos-
tic workups, doctors must face the uncertainty of less infor-
mation. Patients are being pushed out of hospitals earlier,
educing the margin of safety that some physicians would
like. Doctors and ethicists are searching for strategies to
avoid physician responsibility for these cost-based decisions,
so-called "tragic choices" that, like the sun, cause discomfort
when looked at directly.28
C. Why Wo
y?
Why are we so wo
ied about doctors and their dilem-
mas? Lawyers ration care for clients all the time, based pri-
marily on the client's willingness and ability to pay, unless the
suit is a contingency fee liability case. Are medical services
anked higher on a hierarchy of social values and social needs
than legal care? Certainly most individual clients, except
criminal defendants, are not in life-threatening situations.
But neither are most consumers of health care. For those
doctor-patient encounters that involve debilitating diseases,
pain, or the prospect of long term disabilities, however, it is
understandable that we are concerned. Obstetrics, oncology,
treatment of heart disease and diabetes - all involve illnesses
25. See R. FEIN, MEDICAL CARE, MEDICAL COSTS: THE SEARCH FOR A
HEALTH INSURANCE POLICY 168 (1986). Fein gives a good account both of
the relationship of health insurance and rising health care costs, and the
enefits of such insurance.
26. G. CALEBRESI AND P. BOBBITT, TRAGIC CHOICES (1978). These au-
thors were the first to discuss these dilemmas that lack clear answers, create
discomfort, and therefore lead to avoidance or concealment of the conflicts
through a variety of strategies. See also Dyer, Patients, Not Costs, Come First,
16 HASTINGS CENTER REP. 5 (1986).
[Vol. 3
THE ETHICS OF COST-CONTAINMENT
that can end badly. We are unhappy with the older system of
ationing based on ability and willingness to pay, an approach
that restricted access to care in an a
itrary fashion. The
closest legal analogy is state-paid defense of the indigent
criminal defendant, where we view access to legal services as
essential. The legal system is experiencing some movement
toward greater access to a range of legal services, with the
increasing availability of prepaid legal services offered by
some employers. The principle of access to necessary services
is an expanding notion in our culture, and the special claims
of medicine may soon be joined by other professional groups,
as society's definition of need expands.27 The discussion
which follows explores a number of ethical models in search
of a more satisfactory method of rationing health care
services.
II. ETHICS: A GUIDE TO ACTION
A. The Traditional Model
The delivery of health care inevitably involves ethical
problems. Ethics offers guidance to help resolve specific
problems, based upon the application of general moral prin-
ciples. Applied ethics offers "procedures and standards fo
deliberation and justification '"28 in dealing with problems of
health care delivery and therapeutic practice. 9
Ethical discussions have traditionally focused on the phy-
sician-patient relationship and dilemmas of the treatment set-
ting and the immediate life in peril. This ethical focus has
excluded
oader concerns affecting present and future pa-
tients (will medical resources be left for them, after the par-
ticular patient is aided?), or society (is the zealous treatment
of the particular patient necessary or desirable or too
27. See L. FRIEDMAN, TOTAL JUSTICE (1985) for a development of the
cultural forces that have raised our expectations.
28. T. BEAUCHAMP and J. CHILDRESS, PRINCIPLES OF BIOMEDICAL ETHICS
ix (2d ed. 1983).
29. As H. Tristam Engelhardt writes:
The health professions are practiced within a te
ain of concepts
and values that presupposes particular relations between concepts
and values for which philosophers function as the geographers
... .Philosophers can call attention to neglected features, for-
gotten relationships, and unforeseen contradictions. Philosophers
can aid in better mapping and in critically evaluating the concep-
tual and value commitments involved in particular actions and
choices.
H. ENGELHARDT, THE FOUNDATIONS OF BIOETHICS 10-11 (1986).
1988]
JOURNAL OF LAW, ETHICS & PUBLIC POLICY
costly?).30 The explanation for a patient-centered ethic has
een that ethics derived from physicians wo
ied about par-
ticular problems they faced, reflecting an individualistic per-
spective of the "good doctor" and his or her concerns in the
treatment setting.31
Four principles are generally applied to medical inter-
ventions: nonmaleficence, beneficence, autonomy, and jus-
tice. The principle of nonmaleficence derives from the
maxim primum non nocere, translated as "above all, or first, do
no harm." It overlaps conceptually with the principle of be-
neficence, but is usually treated as a distinct principle, as it
ove
ides beneficence in some situations. The principle of
nonmaleficence is defined by Beauchamp and Childress to
mean that "one ought not to inflict evil or harm (what is
ad)." 2 Nonmaleficence resonates for the lawyer in many
tort liability rules based on a standard of care that aims to
avoid harm to others through one's affirmative acts.3 Like
many tort rules, it requires that "agents be thoughtful and
act carefully," minimizing risks created toward others."
Nonmaleficence asks what risks are posed by the interven-
tion, and what level of stress and indignity will the patient
have to endure. It is a first principle, prima facie valid. One
who seeks to violate the principle ca
ies a heavy burden of
justification.
The principle of beneficence goes one step beyond the
principle of nonmaleficence. It derives from a specific moral
30. See generally ETHICS AND HEALTH POLICY xix (R. Veatch and R.
Branson, eds. 1976).
31. See Jonsen and Hellegers, Conceptual Foundations for an Ethics of
Medical Care, 17, in VEATCH AND BRANSON, supra note 30.
In sum, code ethics, as they presently exist, might be called the
archeological ruins of a doctrine of medical virtue. The codes are,
in their present form, collections of pragmatic physician-patient
covenant.
Id. at 22.
32. T. Beauchamp and J. Childress, supra note 28, at 108.
33. Tort law has long adopted the distinction betweep omission and
commission, refusing to recognize any duty to rescue absent a special rela-
tionship. See Restatement (Second) of Torts § 314, illustration 1 (1965).
The nonfeasance principle and its exceptions are well traced in D. DOBBS,
TORTS AND COMPENSATION 406-461 (1985). See also Levmore, Waiting fo
Rescue: An Essay on the Evolution and Incentive Structure of the Law of Affirma-
tive Obligations, 72 VA. L. REV. 879 (1986); Lipkin, Beyond Good Samaritans
and Moral Monsters: An Individualistic Justification of the General Legal Duty to
Rescue, 31 UCLA L. REV. 252 (1983).
34. T. Beauchamp and J. Childress, supra note 28, at 110.
35. Id. at 106-47.
[Vol. 3
THE ETHICS OF COST-CONTAINMENT
elationship of the doctor and the patient. It addresses the
affirmative obligations required of a moral actor, and not just
acts that must be avoided. Beauchamp and Childress sum it
up with obligations: "One ought to prevent evil or harm
.... One ought to remove evil . . . .One ought to do o
promote good.""6 The principle of beneficence thus allows the
actor more discretion than nonmaleficence, requires less risk-
taking, and is more dependent upon roles and relationships."'
The principle of patient autonomy forces the physician
to look at the patient's desires and fears. What is the patient's
desire, once informed of the balance of probabilities? The pa-
tient as autonomous decisionmaker is entitled to make the
cost tradeoffs. How should a doctor respond if a patient has
no insurance and is unwilling to pay for an expensive proce-
dure, or simply decides to forego a treatment after making
his or her own cost tradeoffs? Must the doctor be satisfied
with giving the patient less medical care than is possible, and
less than would in a qualitative sense help the patient?"
The principle of justice is the most difficult to define.
Philosophers and ethicists have not reached agreement on
the common grounds for a principle of justice. 9 The ques-
tion can be put in a cost containment setting, but it conceals
as much complexity as it uncovers in the process. Does the
expected benefit to this particular patient justify the cost in
esources to the community? Justice in the allocation of
36. Id. at 108.
37. Id. at 158.
38. As A. Donabedian writes:
[I]n real life, we do not have the option of excluding monetary
costs from the individualized definition of quality....