Academic journal article Frontiers of Health Services Management

Promisekeeping: An Institutional Ethos for Healthcare Today

Academic journal article Frontiers of Health Services Management

Promisekeeping: An Institutional Ethos for Healthcare Today

Article excerpt


The relationship between a physician and a patient, which survived unchanged for decades-indeed centuries-has in recent years undergone a serious change due to the advent of managed care. Controlling costs and maximizing profits are now as equally important as medical concerns, and ethical, economic, and political issues have forever changed the way physicians perform their duties. This article proposes the concept of promisekeeping as a remedy to the sometimes contradictory positions in which patients and providers find themselves. Composed of honesty, explicit disclosure, flexible decision making, and, most of all, beneficence, promisekeeping is one method to ensure that all parties in the managed care system can succeed.


There is a huge gap between our theories of healthcare and the actualities that exist. But then, throughout history the gulf between what ought to be and what is-what we think of ourselves and what we actually are-has always been bothersome. Perhaps this is part of what it means to be human. It seems that we are very good, sometimes extraordinarily so, at articulating the highest aims of healthcare. Words like quality, continuity of care, holistic, value-driven, patient-oriented, and personal slip trippingly off our tongues as we try to describe the goals of any healthcare management effort, including more recent cost-conscious downsizing and restructuring efforts. Instinctively we know that something has to give when we are no longer building up, but rather cutting back, our healthcare efforts. But we are not willing to abandon the moral high ground when making difficult economic decisions because to do so will acknowledge to ourselves and to others that we are failing to meet our most precious value commitments to one another.

The truth is that moral commitments in healthcare are always and always have been at risk, whether one was either creating a new institution to deliver healthcare or amalgamating others, whether one was overseeing a conglomerate of interests, or whether one was in charge of originating a new form of care. The reason is that the very act of institutionalizing a vision requires compromises with "reality." Some extraordinary individuals, usually the women and men who founded health institutions, combined both idealistic vision with pragmatic organization skills. More often than not, however, visionaries lack pragmatic skills and pragmatists tend to lack vision. Idealistic executives worry that the pragmatists might lose the forest for the trees, while the more pragmatic executive is concerned that the visionary is "out of touch" with the realities of the marketplace. Is there a middle course-a virtue, as it were-that can govern the many managerial actions in the field of healthcare, a virtue that circumscribes a mean between the two extremes of uncompromising principles and coarse selfinterest? In this article I suggest there is, and it is the virtue of promisekeeping.


For centuries healthcare has been delivered primarily within the context of a direct relationship between the provider of care, the physician, nurse, social worker, the hospital, and the recipient of care, the patient, the family, the public. This is now changing. Rapidly, the delivery of care is provided, not by the one most qualified to do so but by an intermediary, a case manager, an entry-level person who tries to juggle both the needs of the patient and the needs of all the patrons in a managed care plan, or the needs of the healthcare system to which she or he belongs. When the provider is the physician, he or she is required by third-party payers to curtail some long-cherished behaviors and values. Compared with the earlier one-on-one transaction, the modern caregiver has become wall-eyed.

In the past, the ethics of the healthcare relationship was spelled out in a Hippocratic ethos. That is, the specific ethical responsibilities of health providers were analyzed within the aureole of a governing set of values for the whole profession. …

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