No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence (review)

This is an informative, interesting and, in many ways, inspirational examination of the ethical obligations, commitments and strategies of a number of health care organizations in the U.S. Written by a team of physician-ethicists, the book's title attempts to capture the ethical tension encountered by every health care system competing for sustainability in an era of managed and competitive health care. No (profit) Margin, No (health) Mission underscores the corporate struggle to find balance between the competing claims of providing quality care to individuals while simultaneously controlling costs for all. From a "realpolitik" perspective, systems of care that cannot make a profit will be unable to achieve other health care goals such as providing an appropriate level of benefits for their enrollees, caring for vulnerable populations, or contributing to the welfare of the community. In other words, success in the marketplace is the necessary precondition for securing other organizational values and objectives. Nonetheless, access to appropriate, timely, and quality health care for persons, especially the poor and marginalized, cannot solely be determined by economic forces. Hence, the very real organizational tension of balancing care with costs goes beyond economic considerations alone and must also be evaluated from the perspective of moral and ethical reasoning. This book attempts to provide the pragmatic ethical lens through which health care organizations can be viewed and challenged, if need be, to change.

Drawing on the results of a 2-year national study (Best Ethical Strategies [BEST] for Managed Care) sponsored by Harvard Medical School, Harvard Pilgrim Health Care, and the National Institutes of Health, the writers seek to identify those health care organizations in the U.S. that demonstrate exemplary ethical commitments and practices. Eight large managed care organizations from across the country participated in the BEST project to learn from one another how to develop ethically appropriate, and economically sustainable, practices that ensure quality of care while controlling spiraling health care costs.

The book is divided into nine short chapters and covers 176 pages. The authors do an admirable job of laying out their premises, goals, and ethical methodology in the initial chapters and then proceed to examine the issues that were the most vexing for the participating health care organizations. These common organizational problems (e.g., appropriate handling of patient information, cutbacks in community contributions, deficits accrued from Medicaid and Medicare reimbursements, and negative publicity regarding rules of coverage and denials) are categorized according to specific ethical domains (e.g., Confidentiality, Community Benefits, Vulnerable Populations, Medical Necessity and Coverage Decisions, End-of-Life Care). However, the authors avoid a dry treatise in normative biomedical ethics by deftly integrating the theoretical with the practical as they describe the specific ethical strategies used by BEST project participants in addressing these particular issues. For example, one of the greatest health care challenges in the U.S. today is how to provide medical care for the sickest and most vulnerable persons (defined as "the disabled, poor, mentally ill, non-English speaking, elderly or very young") while allocating limited resources in a just and sustainable manner. In the chapter entitled "The Care of Vulnerable Populations," the authors examine the general moral foundations upon which this particular social obligation turns while detailing the specific organizational practices of five BEST project participants in meeting this particular moral obligation. The carve in (the organization relies on its own internal resources to meet the needs of an identified population) and carve out (the organization looks to contract with outside agencies to provide the resources) strategies that are vividly outlined highlight the incredible lengths certain organizations have gone to provide care to those who are considered the least well off in our communities. For those of us who work daily with the poor and underserved, it is heartening to learn there are health care organizations that reflect a corporate bias of inclusion, rather than...