Ethical Dimensions of Health System Changes
The US health care system, including its mental health com-ponents, exists in a tremendous state of turbulence and flux at the beginning of the 21st century. The continuing quest for simultaneous achievement of the three goals of quality, acces-sibility and affordability continues to frustrate health policy-makers in both public and private sectors. This quest has resulted in dramatic changes in the structure of our health care delivery system, with the growing replacement of fee-for-service pro-fessionals and institutions by large managed care networks. These structural and operational changes are radically alter-ing the financial incentives that influence provider behavior by rewarding cost containment, rather than generous provision of services.
The proper ethical stance of the psychiatrist in a changing health system is not clear, but the psychiatrist ought to be clear whether he/she is acting as a doctor or citizen. Doctors ethically and zealously advocate for getting whatever they feel is in the best interests for their patients. This may be done without regard for the bigger picture of resource allocation. For the doctor, the patient comes first.
As citizens, however, psychiatrists also have a responsi-bility. Society makes determinations of how big the pool of re-sources will be, what illnesses are covered under insurance, and how much a clinician will be paid. Psychiatrists have a unique perspective and expertise on the consequences of these decisions, and in their citizen and public policy role will do well to par-ticipate in the difficult and ethically challenging work of creating and influencing policy decisions affecting their patients, profes-sion and society.