Discussions of managed care frequently begin and end with an opposition between the Hippocratic ethic of dedication to patient welfare and a business ethic of self-interest in the service of efficiency. In The Ethics of Managed Care: A Pragmatic Approach, Mary R. Anderlik approaches managed care as a problem of organisations. Rejecting analysis in terms of a simple dichotomy of "medicine vs. business," she argues that attention should be directed to management as manipulation, the neglect of internal goods such as satisfaction in professional accomplishment, and three kinds of moral myopia associated with organisations.
In this account, "pragmatic" suggests practical idealism, not the jettisoning of principle in the interests of expediency. Anderlik favors a broad empiricism and a moral vision centred on values of democracy and community. It follows that an important aspect of the evaluation of organisations is an assessment of their effects on the quality of social relationships. Anderlik describes how organisations can nourish or destroy human potentialities for openness, creativity, cooperation, and faithfulness – and display "virtues" such as justice, integrity, responsiveness, and efficiency rightly understood. A case study illustrates the potential for realisation of significant individual and communal goods within managed care organisations as well as the dangers and difficulties that bedevil even the best of them.
Anderlik uses community care clinics, asthma outreach programs, and new contexts for participatory decision-making to show the promise of managed care. She also explains the complexities of financial arrangements, arguing for an end to schemes that reward clinicians for providing less care and make it profitable to avoid people who need a lot of care. She finds that other practices, such as use of guidelines or gatekeepers, require a more subtle analysis. Guidelines as best practice advisories and one tool for quality improvement are contrasted with guidelines as rules for saving money purporting to be best practice advisories or objects of faith. Gatekeepers as mentors, coordinators, judicious users of services and points of accountability are distinguished from gatekeepers as stern enforcers of "autonomous" choice and indifferent obstructionists. The book concludes with a look at the future of managed care, outlining a positive program for reform.