QUALITY OF NEUROLOGICAL CARE - BALANCING COST CONTROL AND ETHICS

As the quality of neurological care becomes a mutual objective of phys icians, patients, and health planners, increased demands on cost savin gs will create conflicts that could threaten the ethical basis of medi cal practice. Physicians will see increasing ethical conflicts between their fiduciary duties to make treatment decisions in the best intere st of their patients and their justice-based duties to conserve societ al resources. These conflicts can be best mitigated if physicians main tain their orientation as patient advocates but practice cost-consciou s clinical behaviors that consider the cost-effectiveness of tests and treatments and do not squander society's finite resources by ordering medical tests and treatments of zero or marginal utility. Health syst em planners should resolve their conflicting objectives of quality and cost control by rigorously defining and measuring quality through phy sician leadership and by implementing cost-control measures that enhan ce the quality of medical care. Managed care organizations voluntarily should forsake financially successful but blatantly unethical cost-sa ving schemes, such as gag clauses and end-of-year kickback payments to physicians, because these schemes diminish patients' trust in physici ans and degrade the integrity of the patient-physician relationship. S tate and federal laws should prudently regulate these unethical cost-s aving schemes to the same extent as they have for the harmful conflict s in fee-for-service medicine.