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Book Review   |    
The Ethical Way: Challenges and Solutions for Managed Behavioral Healthcare
Philip Candilis, M.D.
Psychiatric Services 1998; doi:
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by H. Stephen Moffic, M.D.; San Francisco, Jossey-Bass Publishers, 1997, 234 pages, $34.95

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The penetration of managed care is now complete. Discussion of how to rein in costs and yet maintain good patient care is now almost shelved on the fiction rack. The Ethical Way recounts the struggle of a fictional managed care company to address the seminal issues at the intersection of business and medicine. The founders of the company, who are aptly named Adam and Evelyn, take readers through their creation of this new company and the choices they must make to ensure its survival as an ethical institution.

Author Steven Moffic has considerable experience in managed care control of psychiatric services. His introductory chapter describes the changes already brought to his academic and public-sector colleagues at Baylor. Unfortunately, the changes he describes include average inpatient stays of four days, average outpatient treatment of seven sessions, and the bulk of care provided by master's-level clinicians. His view of these developments as positive eventualities color the book that follows.

As easy as the book is to read, its analysis of the major ethical issues is ultimately unsatisfying. Arguments for and against the usual managed care interventions are offered as discussions among colleagues or as plot-line, a pleasant-enough presentation, but the commentary at the end of each chapter comes largely from business experts. The concerns of deciding how much (or even whether) to profit from health care services, how to balance limited resources under capitation against the individual needs of patients, and the role responsibilities of each clinician in deciding how and when to ration care are simply not addressed. The emphasis on business ethics is discouraging. A reliance on financial incentives to drive sound professional judgment is demeaning to health care professions who derive their mission from principles of beneficence and nonmaleficence.

The conflicts of interest raised by the ascendance of a financial-incentive model are far more stark than those previously encountered by the patient-clinician relationship. The subtle chicanery of ordering too many tests or referring patients to one's own lab has been replaced by a concerted methodology that overtly ties utilization to profits. This basic problem merits scrutiny even in a work of fiction.

Moreover, the lack of justifications for changing focus from individualized to population-based treatment underscores the need to address this brave new world of bedside decision making. When a clinician serves not only his or her patient but those of the entire organization, conflicts generally described as those of double agency arise. The usual role of patient advocate is constrained in ways not usually clear to patients, who expect the best advice about their particular case. Fictionalizing these conflicts does little to diminish their gravity.

The irony of how the company obtains its first contract will not be lost on most readers: a consultant puts in a good word with another company that wants to subcontract mental health care through a carve-out. A book entitled The Ethical Way that accepts the ethics of inside tracks and carve-outs cannot be considered a success.

Dr. Candilis is associate director of the office of ethics at the University of Massachusetts Medical Center in Worcester.

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