Ethical tensions in the physician-patient relationship within managed care

By reviewing the various core activities and skills within the physician-patient relationship, this article provides a balanced conception of what physician advocacy should amount to, especially within the milieu of managed care. The contrasting generic models of such advocacy, that is, 'individual patient based' and 'population based' advocacy, are initially reviewed and each is found wanting as comprehensive accounts of the fiduciary obligation that physicians owe patients. This article then illustrates how each of these two orientations must be held in a balanced tension within the patient-physician relationship to do proper justice to the goods and values involved. Concurrently, it is argued that such tensions are not simply artifacts of managed care, but would exist within any health care delivery system that satisfied some minimal standards of fiscal discipline and scientific accountability.