An advocate speaks on behalf of the interests of another. Although this has traditionally been understood as the role of a qualified representative in a formal legal setting, it has more recently become the role of health care providers whose patients are unable to speak for themselves. Pediatricians commonly regard themselves as advocates in two senses that are not always distinguished: for the children who are their patients or as citizens with a special expertise for the entire population of children. This article will consider the ethical responsibilities of pediatricians who work in health maintenance organizations (HMOs) in their role as advocates for the children who are their patients.
THE PEDIATRICIAN AS PATIENT ADVOCATE
The role of the pediatrician as a patient advocate in general, apart from any particular form of health care delivery system, will be considered first. It is assumed that whatever model of the doctor-patient relationship one adopts, all physicians are obligated to serve as advocates for their patients. Does the pediatrician have an advocacy responsibility that is essentially different from that of other physicians?
One generic fact of the doctor-patient encounter is the vulnerability of the patient. This vulnerability generates the physician's moral obligations to the patient.! People who are ill present themselves to the physician as uncomfortable, uncertain, anxious, and fearful. Adult patients who are ill have usually fallen from a normal level of competence and strength. As patients, children are no different, although very young children may not perceive themselves as ill and therefore vulnerable in this sense.
Children are vulnerable in another sense that adults usually are not. Because of their age, children are subject to the control of others. They lack political and economic power in society. Yet the same may be said of many other groups, such as the mentally retarded. What distinguishes children from these others?
One answer may be that children have still less legal control over their lives than others who lack power, but even this is not always so. Some "mature" or "emancipated" minors may be granted many of the legal rights of adults. Rather, what distinguishes children is the unique form of their vulnerability: in the normal course of things they will develop from a position of powerlessness into one of power. No other group has this inherently receding form of vulnerability.
The receding vulnerability of children arguably generates certain special responsibilities of their physician-advocates. In general, one might say that the pediatrician is a kind of expert guide. In an alliance with parents, the pediatrician helps to deliver the child safely to the shore of adulthood, whereupon the child may assume the relatively independent status that is the goal. This image suggests that, while parents are society's "trustees" for the child,2 the pediatrician is the recognized "caretaker" or "custodian." As a trustee the parent has persistent and ongoing responsibilities for the child, while as caretaker the pediatrician periodically provides skilled expertise and technical support.
A critical part of this special advocacy role is fostering a cooperative relationship with the child's trustees.
Without this "therapeutic alliance" with parents the pediatrician as advocate can hardly hope to achieve the ultimate aim: the successful delivery of the child to the relative independence of adulthood. Therefore, the conceptual framework of the pediatrician's advocacy role is that of an ally of parents rather than that of a socially appointed watchdog.
THE HMO AS MORAL AGENT
Ethical concerns in the HMO have been discussed. 3 The moral obligations of the HMO in its function as health care provider may be summarized as follows:
1. A duty to a level of skill (ie, competence);
2. A duty to make that skill maximally available to the patient (even at some personal cost);
3. A duty to act as the patient's advocate.5,4
The duty to a level of skill implies that practitioners' credentials will be in order and conferred by accredited institutions. But in the HMO setting, with its "gatekeeper" system, an important question is whether this duty is consistent with establishing checkpoints on access to specialty care. One solution for the HMO is to obtain physicians who can provide care approximately equivalent to that of a specialist and exercise prudent referrals. Obviously the physician in a primary care practice cannot achieve the same level of expertise in a particular field as the practicing specialist. Hence those with special interests should be encouraged to supplement their irregular exposure to such problems by pursuing, for example, continuing education opportunities.
The duty to make that skill maximally available to the patient implies that technologies such as diagnostic tests will be ordered as needed. Unfortunately, interpretations of "appropriate ordering" can vary, particularly between physicians and patients. The "marginal test" is attractive to the fee-for-service physician because it may be risk free, as in the computerized tomography (CT) scan for headache, and because it may reassure the patient that action is being taken.
However, HMO physicians may be more reluctant to order the same test, even apart from financial incentives, because they are intrinsically more oriented to take cost into account.5·6 How can patient annoyance and frustration be balanced against the avoidance of overtesting, which can have adverse medical and financial consequences by leading to overtreatment through false-positive results? It seems that the HMO must exercise full disclosure about its operating conditions while actively educating its public about the riskbenefit/cost-benefit dilemma. Ideally this would involve discussions of this root problem for any managed health care system.
The duty to patient advocacy protects against conflicts of interest that can affect any form of medical practice. Perhaps the HMO's explicit acknowledgment of financial constraints on health care is partly what has gained it special attention in this regard, in a society reluctant to come to grips with this reality. There is no question that the HMO setting can spotlight situations in which individual and group interests are incompatible. Often it will be in the physician's financial interest to act as an advocate for a group of patients and not only for an individual. However, is this inconsistent with the physician's moral obligations as well? It would be narrow to assume that physician advocacy can only be directed to individuals. Indeed, public health campaigns have long relied upon a community ethic that sets the interests of the group as primary.7·8 Perhaps such an ethic has a place elsewhere in health care, such as the HMO.
These remarks on the ethical responsibilities of the HMO refer mainly to the staff model HMO where the patient panel is entirely or largely closed to all but HMO clients. The independent practice association consists of individual physicians in separate offices with "mixed panels." This latter arrangement raises additional moral questions to those addressed above. 3
THE PEDIATRICIAN AS ADVOCATE IN THE HMO
The duties of competence, availability, and advocacy can now be applied specifically to the practice of pediatrics in the HMO. The duty to a maximum level of skill or competence does not seem to create unique obligations for the pediatrician. However, in practice it may be the most difficult for all physicians to implement. There are obvious obstacles for primary care physicians to provide care that is approximately equivalent to that of a specialist. In their advocacy role HMO pediatricians, like their colleagues in the organization, should consider ways to realize the aims of this duty.
The HMO also has a duty to make its skills maximally available to the patient. Since the HMO is the physician for a class of patients, the individual physician as an officer of the HMO must undertake frequent cost-benefit analyses in the use of diagnostic tests and other technologies. In a collaborative relationship with a child's parents, the HMO pediatrician will have to pay special attention to engaging with them in a cost-benefit analysis, stressing especially the costs to the child in overtesting.
Yet, as noted above, since pediatricians ordinarily make health care decisions in a collaborative process with parents, it may be somewhat more difficult for them to follow through on cost containment strategies even though these are consistent with the medical best interests of the child. Often, parents are motivated by irrational factors such as guilt about their child's illness. To maintain the therapeutic alliance, the pediatrician may tend to be more flexible about cost factors than strictly medical prudence requires.
In addition to presupposing the performance of the first two duties, the duty of patient advocacy exerts its own obligations. For example, in some instances the complaining, febrile, squirming child will be more difficult to evaluate than the adult, who is more likely to comply readily with a clinical examination. Therefore, diagnostic tests that might be regarded as unnecessary upon examination may be ordered more frequently in pediatrics. This factor in the care of the child may not be well understood by those accustomed to examining adult patients.
To take another example of pediatric advocacy in the HMO, one may assume that all patients should receive services appropriate for their place in the life cycle. Thus, all young patients and their parents should have the opportunity for lengthy office visits during the first two years of life in which there is ample time to discuss a very wide range of issues of early child development. This policy can lay the foundation for the caretaking relationship mentioned earlier. Without it, the long term developmental concerns inherent in pediatric care will go unsatisfied. This extra time for "cognitive services" may be considered as establishing preferential treatment for one subgroup of HMO patients (children) at the expense of another (adults). However, it should be seen as fulfilling part of the implied obligation to act as an advocate for patients as is appropriate at their particular stage of the life cycle.
There is no reason to believe that the HMO pediatrician cannot maintain the highest standards of ethical practice. For this to be achieved there should be a clear understanding of the moral responsibilities of the pediatrician specifically and the HMO generally. This understanding may require certain adjustments to the unique circumstances of pediatrics. Yet there are obvious long term benefits in a relationship with a young patient and family who have reason by virtue of their experience to continue their HMO membership.
1. allegrino ED: Humanism and the Physician. Knoxville, Tenn, University of Tennessee Press. 1979.
2. Shelp E: Bom u> Die! New York. Free Press, 1987. pp 26-49.
3. Rivar G. Moreno JD Hippocrates and the HMO Ann Intern Med 1988; 109:419-424.
4. Pellegrino ED, Thomasma DC: A Philosophical Basis of Medical Practice. New York, Oxford University Press. 1981. pp 201-219.
5. Eisenberg JM; Sociologie influences on decision-makinE by clinicians. Ann Intern Med 1979; 90:957-964.
6. Eisenberg JM: The internist as gatekeeper. Ann Intern Med 1985: 102:537-543.
7. Beauchamp D: Community: The neglected tradirion of public health. Hastings Cent Rep 1985: 15:28-36.
8. Moreno JD, Bayer RB: The limits oí the ledger in public health promotion. Hastings Cent Re> 1985; 15:37-41.