MANAGED CARE - RATIONING WITHOUT JUSTICE, BUT NOT UNJUSTLY

Three ethical criticisms of managed care are often voiced: (1) by ''sk imming the cream'' of the patient population, managed care organizatio ns fail to discharge their obligations to improve access, or at least, to not worsen it; (2) managed care organizations engage in rationing, thereby depriving patients of care to which they are entitled; and (3 ) by pressuring physicians to ration care, managed care organizations interfere with physicians' fulfillment of their fiduciary obligations to provide the best care for each patient. This article argues that ea ch of these criticisms is misconceived. The first rests on the false a ssumption that the health care system includes a workable division of responsibility regarding access that assigns obligations concerning ac cess to managed care organizations. The second and third criticisms wr ongly assume that we in the United States have taken the first step to ward assuring equitable access to care for all, articulating a standar d for what counts as an ''adequate level of care'' to which all are en titled. These three misguided criticisms obscure the most fundamental ethical flaw of managed care: the fact that it operates in an institut ional setting within which no connection can be made between the activ ity of rationing and the basic requirements of justice.