21A.216J Dilemmas in Bio-Medical Ethics
2005/3/7 (M), Week 6, Class 10
Howard Hiatt, “Protecting the Medical Commons: Who is Responsible,”
Journal of Medicine
, Vol 293, No 5 (July 31, 1975): 235-241
Howard Hiatt, MC Weinstein, “Will Disease Prevention Spare the Medical Commons?”
Ciba Found Symp.
, Vol 110 (1985): 218-35.
Laurie Zoloth-Dorfman, Susan B Rubin, “The Patient as Commodity: Managed Care and
the Question of Ethics,”
Journal of Clinical Ethics
, Winter 6, No 4(1995): 339-357.
Short Paper 1 handout.
Percent of GDP spent on healthcare, 1998:
US-42; Canada-75; Australia-70%; Sweden-90%; Japan-75%; Italy 79% (down from
84% in 1980); UK-84%; US spends the most but leaves out undocumented workers,
immigrants; many children of immigrants are citizens but have no care
Managed care enrollments in US: 1985-7%; 1995-75%
“Protecting the Medical Commons: Who is Responsible?”
Background: Hiatt, BIDMC, HMS, health disparities studied through education, training
Introduction: Medical commons – uses a metaphor of sheep grazing, overgrazing on
available resources; freedom in commons brings ruin to all. Are we destined to problems
and what kind of precautions that we can take?
Question: Page 1. The principle that doctors should do everything possible for the
individual patient—a luxury for all patients. Gawande—doing everything they can to
avoid cutting off her leg vs. most patients lucky to even be alive.
Was it right of them to
use those resources and time for the patients?
Quality of life of patient vs the individual doctor worried about distribution of
Luxury of a hierarchy of how many patients, etc., as decided by managed care
Concierge/Retainer/Boutique medicine—flat fee to the patients and a new way of
paying for health care, the doctor is responsible for providing or limiting care. An
overall hierarchy to distributing care. How does that differ from fee for service?
Flat amount per year vs fee for service; a whole other tier of care
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