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The changing practice environment
Many individual persons, groups and institutions play a role in and are affected by medical decision making in the current practice environment. Tension and competition among the interests of clinicians, insurers, patients and institutions for available social and health care resources unavoidably influence the patient–physician relationship.

Although this section of the Manual will focus specifically on the obligations of physicians in this changing context, it is essential to note that others, such as insurers and health care institutions, bear responsibility for ensuring that the fundamental ethical commitment between physicians and patients is not undermined. The patient–physician relationship and the principles that govern it should be central to the delivery of care. These principles include beneficence, honesty, confidentiality, privacy and advocacy when patients’ interests may be endangered by arbitrary, unjust, or inadequately individualized institutional procedures. Health care, however, does take place in a broader context beyond the patient–physician relationship. A patient’s preferences or interests may conflict with the interests or values of the physician, an institution, a payer, other members of a managed care plan who have equal claim to the same health care resources, or society. The physician’s first and primary duty is to the patient.

Physicians must base their counsel to patients on the interests of the individual patient, regardless of the insurance or medical care delivery setting in which physicians find themselves. Whether financial incentives in the fee–for–service system prompt physicians to do more rather than less or managed care arrangements encourage the physician to do less rather than more, physicians must not allow such considerations to affect their clinical judgment or counseling on treatment options, including referrals for the patient. The physician’s professional role is to make recommendations on the basis of their medical merit and to pursue options that comport with the patient’s unique background and preferences.

Physicians should also contribute to the responsible stewardship of health care resources. With clinical authority and discretion come responsibility. Parsimonious care that utilizes the most efficient means to diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available. The recommendations of physicians to patients, in the design of practice guidelines and formularies and to medical benefits review boards should reflect the best clinical literature. Recommendations should, as much as possible, consider data on the cost–effectiveness of different clinical approaches. When patients ask, they should be informed of the rationale that underlies the physician’s recommendation. Patients may not understand or may fear conflicts of interests for physicians and the multiple commitments that can arise from cost–containment under managed care. Health care plans have duties to foster an ethical practice environment. They should hold physicians accountable for the quality of care and not simply for economic performance. Managed care plans should not restrict the information or counsel that physicians may give patients.