Produced for the
Substance Abuse and Mental Health
Services Administration (SAMHSA) 1998

The opinions expressed herein are the views of the authors and do not necessarily reflect the official position of the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Care Financing Administration (HCFA), or the U.S. Department of Health and Human Services.

Introduction

Ethical principles permeate health care. The admonition to "do no harm" is an ethical statement, as is the idea that a patient's welfare must come before the financial interests of the treatment provider. Ethical concerns also are central to debate regarding the overall allocation of health care resources. For example, is the Oregon Medicaid plan, which explicitly rations health care, a "just" approach? If resources are limited, should our allocation policies favor individuals with illnesses that might be cured at the expense of individuals at the end of life?

Ethical issues also are at the core of behavioral health care. For example, two important issues are capacity and autonomy. Individuals are presumed to be able to make decisions regarding health care; however, that right is limited to those with the capacity to make an informed choice.

In the past, the ethical issues most affecting behavioral health care practitioners were those involving the exploitation of clients--for example, sexual or financial exploitation. In addition, the fee-for-service system may have created financial incentives to "overtreat" individuals. As a result, ethical and legal principles typically were concerned with protecting patients from decisions motivated by clinicians' self-interest. Examples include Federal and State laws prohibiting physicians from referring patients to laboratories in which the physician has a significant financial interest.

Managed care presents different challenges. Its emphasis on cost containment changes in fundamental ways the therapist-client relationship. The therapist in today's behavioral health care system often enjoys less discretion than he or she enjoyed in the traditional fee-for-service system. Cost is a much more explicit concern; payers may involve themselves in individual treatment decisions. The central ethical questions in a managed care environment flow from this changed therapist-client relationship. For example, what is the therapist's obligation if he or she believes the client needs additional care but there is no money available to pay for such care? Is the therapist obligated to discuss with the client economic limitations on treatment if the client decides to enter a therapeutic relationship? What role does coercion play in a managed care environment?

There are also ethical issues for the behavioral health care organization in this new environment. What impact might business decisions have on ethical issues faced by therapists who implement those decisions? Are there ethical issues involved in the marketing of a managed care plan? Is there a role for an ethics committee in a behavioral health care organization? The debate regarding the ethical principles that should inform the overall allocation of health care resources also has intensified as the view that health care expenditures must be limited has gained strength. For example, should health care be rationed? If so, for whom and by whom? Should the treatment provider be expected to consider societal interests within the context of the therapeutic relationship?

This monograph explores a number of core ethical issues in managed behavioral health care. The first section discusses briefly the ethical principles underlying debate regarding the overall allocation of health care resources. The second discusses in general terms key ethical principles informing the treatment relationship. These include the fiduciary obligation of treatment providers to their clients, autonomy of the individual in making health care decisions, and informed consent. The third section discusses the impact of managed behavioral health care on these principles, and the fourth discusses ethical issues confronting the behavioral health care organization in a managed care environment. The monograph concludes with a discussion of how individual practitioners and behavioral health care organizations might respond to these ethical dilemmas.

One ethical/legal topic not addressed in this monograph is confidentiality, which is covered in a separate monograph in this series. In addition, this monograph does not concern itself explicitly with ethical issues from the perspective of the managed care company; rather, it focuses on issues from the perspective of the practitioner and behavioral health care provider.