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The Changing Face of Health Care
  1. Deirdre Fetherstonhaugh
  1. Caroline Chisholm Centre for Health Ethics Melbourne, Australia

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    Edited by John Kilner, Robert Orr and Judith Shelley, Michigan, Wm B Eerdmans Publishing Co and Cumbria, Paternoster Press, 1998, 314 pages, US$19.00.

    In the words of the editors, this book is “an honest attempt to grapple with the often-conflicting matters involved in the changing face of health care” (page xii). This “changing face” refers specifically here to the American style of managed care. However, by implication it also applies to other health care systems where resources are being rationed and schemes have been in put in place to achieve this end.

    Managed care has received much criticism, mainly from those health care practitioners who work at the coalface. Managed care has changed the face of health care because it restricts the autonomous practice of physicians to acting in what they see as the best interests of patients. Under managed care, health care interventions have to be authorised by business enterprises (HMOs), health has been commodified, profit has become a driving incentive and, as this book describes, Christian principles and responsibilities are being compromised.

    This book urges Christians to understand and debate the issues raised by managed care and the allocation of health care resources and to become actively involved by supporting the good aspects and reforming the bad. I do, however, think that some of the suggestions made by the contributors arise from a rather idealised view of the world and of human nature.

    The Changing Face of Health Care is organised into five parts with a glossary and a concluding chapter written from a British point of view. This chapter, written by Stuart Horner, adds credence to the book by assuring the reader that problems such as those experienced under managed care, are global and not country-specific. The first part of the book includes the reflections of personal experiences of managed care. Part two provides insight into the practices of medicine and nursing and also looks at concepts of justice and rationing. The third part discusses the concerns raised when economics and business encroach on patient care. Part four concentrates on the impact of health changes in particular settings, such as mental health, long term care and minority communities. This part concludes with an interesting chapter on the impact of managed care on malpractice. The fifth part attempts to provide some constructive responses to the challenge of managed care but I personally do not see these as achievable on a large scale.

    Throughout the book there are many biblical references that sometimes enhance the argument, but often do not help with any definition of the problems inherent in managed care, and how to solve them.

    Perhaps one of the most useful contributions to this book is that of Kenman Wong who very coherently discusses both business and medicine, showing that for each to be ethical and successful they do not necessarily have to operate at opposite ends of the spectrum. He concludes his paper by giving “some examples of the ethical responsibilities that can be assigned to managed care organisations based upon business ethics” (page 147).

    This book makes a useful contribution to the discussion of managed care but with so many contributors some of the discussion is repetitious. After reading this book however, one does feel the need to try and address the conflict between the rights of the individual and the requirements of a broader collective society (page 292).