March 19, 1999

I am writing in response to an article in the November 20, 1998, issue regarding ethics and the managed care review process. This is an oxymoron. The fundamental ethic of clinical care is in direct conflict with the fundamental ethic of "managed care." The process of trying to find a compromise is like trying to find a rationale for a pirate to keep on practicing his (or her) piracy, unless you believe that corporate interests have a right to control everything they can-in order to enrich themselves at the expense of others. I don't.

The whole managed care movement is based on the idea that our profession grew fat and lazy during an era of bygone prosperity. The only way we would be brought into line with the new, efficient, Y2K-compliant cybereconomy would be to starve us into submission. The managed care companies were the thugs elected to bring us the news. They dieted, massaged, poked, and cut us, and we responded, becoming as svelte as supermodels, and now they want us to try diuretics and laxatives and maybe a liposuction or two. Meanwhile their own bureaucracies have absorbed our old inefficiencies and luxury. They are the ones who are not accountable and keep dodging the consequences of their actions while, naive in-house doctors continue to sell out patients and colleagues. They are the ones with the inflated salaries, corporate perks, and rafts of writeoffs. Not us.

The quality of care under managed care stinks. It has from the beginning, and it will continue to do so until managed care gets out of the way of patient and doctor freedom. Efforts like developing ethics guidelines for managed care review are futile exercises in self-justification and have nothing to do with honest debate about corporate power, methods in capitalism, general economics, and various forms of tyranny.

Patrick B. Mullen, M.D.
Greenville, S.C.