THE ETHICS OF ACCOUNTABILITY IN MANAGED CARE REFORM

Two notions of accountability embodied in proposals to reform managed care have different ethical implications. Market accountability requir es plans to inform purchasers and consumers about performance and opti ons, in theory legitimizing limits to care through consumer choice. Re cognizing the limits of consumer choice, accountability for reasonable ness requires that the rationales for limits to services be public and be based on reasons or rules that ''fair-minded'' people can agree ar e relevant to pursuing appropriate patient care under necessary resour ce constraints. Accountability for reasonableness educates clinicians and patients about the need for limits and empowers a more focused pub lic deliberation in which ultimate authority for limiting care rests w ith democratic processes.