Kenman L Wong, Notre Dame, Indiana, University of Notre Dame Press, 1998, 232 pages, $32.00

Health care in our society has reached a critical point in its evolution. Numerous articles have decried current approaches to health care reimbursement by focusing on their negative impact on patient relationships. However, few have reflected on the encroaching import of business ethics on these relationships. Kenman Wong's book Medicine and the Marketplace is a critical first beginning of this reflection. Wong engages in a comprehensive ethical assessment of managed care and the impact of business ethics on obligations to patients. As Wong rightly observes, the ethical discussions concerning health care and its economics, focus on obligations of physicians not those of institutions or other health care professionals. However, health care institutions are increasingly interposed between the physician and patient and their decisions are based on business ethics. The book begins by reviewing the history of business and medicine. To describe medicine as being free from the world of money is patently wrong. However, there is increased concern about the foundational morality of the current managed care approach to reduce health care expenditures. The tension is that “the traditional `good' for business has been and continues to be profit, while the `good' for medicine is the wellbeing of patients”.

Wong describes the moral typology of managed care as six ethical views in two categories. Those critical of managed care are:1) patient-centred purists; 2) market reform purists; 3) explicit rationers, and those in support of managed care are: 4) for-profit managed care champions; 5) non-profit organisational supporters, and 6) cautious managed care supporters. Wong's criticism of each of these approaches is well presented and his discussion illustrates that “a simple dichotomy, for and against managed care, obscures the moral (and practical) issues of the managed care debate”.

Wong realises that the answer to limited health care resources cannot be found in either increasing non-profit organisations or in a re-enforcement of the physician's advocacy role. Non-profit organisations have not always been altruistic nor patient-centred and must realise a profit, no different than for-profit institutions. To Wong the differences between for-profit and non-profit are illusory and health care an industry that is “far too complex to be run by missionaries and candy-stripers”. However, Wong is not an unrestrained free market champion. “A restrained marketplace is necessary to protect the rights of all parties.” The question is how the two, “business and medicine, whose missions apparently follow widely diverging paths”, can be integrated effectively.

Wong supports a view of health care business ethics called stakeholder theory. He believes that “a stakeholder approach can be formulated” to support essential values in health care. Wong feels that managed care organisations should be “held to behavioral standards which are consistent with the objectives of service to the community through the provision of quality health care” and correctly observes the tension between the two roles of health care institutions, ie, businesses and delivering health care. However, “adequate moral grounds ... cannot be found in the traditional understanding either of medical or of business ethics. The traditional patient-centered ethic is unrealistic and irresponsible” and he sees hope in an “enlightened stakeholder approach” as an ethical framework to govern the behaviour of managed care organisations.

Although Wong takes a very important first step in an analysis of business ethics in health care, stakeholder theory does not provide the ethical framework he hopes for. It does provide an important first step, ie, identifying stakeholders, however, it does nothing to help rank stakeholder interests, which is the critical tension in health care today. For example, how do we rank the interests of patients against those of the health care institution? Wong's book is a critical and important first step in the debate on managed care and the discussion of business ethics in health care. It should be read by anyone interested in medical ethics.