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Taking Issue   |    
Ethics in Managed Care
James E. Sabin, M.D.
Psychiatric Services 2004; doi: 10.1176/appi.ps.55.5.475
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Several years ago a New Yorker cartoon showed a group of earnest preteen girls sitting on the floor of a bedroom, deep in conversation. One child notices a parent standing at the door. The caption reads, "Leave us alone, Mom. We're talking about values!"

Another New Yorker cartoon shows nine men sitting in a boardroom listening intently to their leader, who has just asked them: "So we all agree that this action is unethical. Is that a problem for anyone?" Are "real world" health care executives like the men in the cartoon boardroom? In a U.S. health care system that uses market forces to determine organizational success and failure, aren't people who talk about ethics like the children on the bedroom floor—sincere and well-meaning but ultimately irrelevant to the concerns of the boardroom?

The article by Dr. Halpern and her colleagues in this issue demonstrates that ethics can be more than public relations fluff and that "ethical managed care" need not be an oxymoron. These authors show how abstract ethical concepts like "autonomy," "beneficence," and "distributive justice" can be defined in operational terms, promoted by managerial strategies, and measured to ascertain results. The study used the tools and language of management—dare I say it, of managed care—to enhance performance and accountability for values that are more typically addressed by means of pious pronouncements and hand-wringing.

A chief executive officer who says, "Ethics is fine, but we have to make a business decision here" is revealing muddleheadedness and ineptitude, not leadership. For an organization to have long-term success, "CEO" must also stand for "chief ethics officer." If you doubt this, check with former Enron employees.

As mental health clinicians we know how to help our patients deal with the ego mechanism of splitting. We need to help ourselves in a similar fashion with the widespread tendency to polarize "business" and "ethics." By putting care values and social justice concerns into the silo of "ethics," we foster not only idealization—as depicted by the earnest preteen girls in the first cartoon—but also Enron-style macho disparagement—as depicted by the men who cheerfully embrace the unethical path in the second.

Abstract debates about the relative importance of "ethics goals" and "business goals" get us nowhere. Better to have healthy fights about how much to invest in which goals for what reasons. As Harvard Business School professor Lynn Sharp Paine showed so clearly in her book Value Shift, organizations that merge social, ethical, and financial imperatives do better in the long run. We should demand that health organizations conduct this kind of debate openly and thoughtfully.




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