The author asserts that physicians have two fundamental duties: they must balance the interests and wishes of the patient with the welfare of the health care system in which they practice. In fact, many physicians actually act in accordance with this dual approach, but they sense an inconsistency between their behaviors and their ideals, which focus on the patient only. The author explains why, as a consequence of this more complex role, medicine must stop viewing the case manager as the unavoidable but unwanted child within the family of medicine and must incorporate case management within the very identity of the physician. Finally, the author explains in detail that when the physician practices according to the dual-stewardship model just described, at least three beneficial consequences will emerge. First, the abysmal quality of end-of-life care in the United States may improve. Second, restraints on funding for last-chance or experimental treatments may, surprisingly, advance patients' interests. Third, an admission that much is not known about many mental illnesses and an acknowledgment that the money spent in treatment often yields limited results may encourage the health system to resist providing unproven treatments. This admission should also lead to more scientific knowledge and more effective approaches to these bewildering problems.
In conclusion, the author states that it is not just the physician who must redefine himself in the new world of medicine. Administrators of managed care organizations must face the challenge of redirecting their traditional commitments to stockholders and boards of directors toward the patient-centered values of the physician.
Dr. Minogue is professor of philosophy, Department of Philosophy and Religious Studies, Youngstown State University, Youngstown, Ohio. He is also a bioethics consultant for Forum Health Care of Youngstown, Ohio, and for Sharon Regional Hospital of Sharon, Pennsylvania.
Correspondence and request for reprints should be sent to Dr. Minogue, Department of Philosophy and Religious Studies, Youngstown State University, One University Plaza, Youngstown, OH 44555-3448; telephone: (330) 742-1627; fax: (330) 742-1600; e-mail: 〈email@example.com〉.
For a Commentary on this article, see page 443.