Captive Patients, Captive Doctors:
Clinical Dilemmas and Interventions in Caring for Patients in Managed Health Care

Harold J. Bursztajn, M.D.
Archie Brodsky, B.A.
General Hospital Psychiatry
1999, 21:239-248
Revised, March 23, 1999

From the Department of Psychiatry, Harvard Medical School, Boston, MA (both authors).

Corresponding author: Harold J. Bursztajn, M.D., e-mail: harold_bursztajn@hms.harvard.edu
Running title: Captive Patients, Captive Doctors
Key words: alliance, captive, choice, helplessness, managed care

This paper is based in part on two presentations by Dr. Bursztajn: "Medical Historical Perspectives Regarding Managed Care and Medical Necessity: True and False" (American Psychiatric Association Annual Meeting, San Diego, CA, May 19, 1997); "Medical Necessity, Managed Health Care Denial of Benefits, and the Nuremberg Code" (Princeton University 250th Anniversary Symposium, Princeton, NJ, May 29, 1997).

Acknowledgments

The authors thank Patricia M.L. Illingworth, Ph.D., J.D., and members of the Program in Psychiatry and the Law for clarifying dialogues, Paul S. Appelbaum, M.D., Jeremy A. Lazarus, M.D., Alan A. Stone, M.D., and Uwe E. Reinhardt, Ph.D. for their contributions to panels in which the ideas presented here took shape, and Irene Coletsos, B.A., Thomas G. Gutheil, M.D., Robert Moynihan, B.A., and Richard Sobel, Ph.D., for their sensitive readings of previous drafts.

Abstract

This article explores common clinical dynamics resulting from the denial of choice that many patients experience in managed health care and proposes clinical adaptations for the treating or consulting psychiatrist. Patients who feel they have been denied the right to choose their health plan, treatment setting, or personal physician commonly go through a subjective experience analogous to that of being held captive. This sense of captivity can exacerbate the feelings of helplessness and hopelessness brought on by serious illness. It can also intensify the patient's feelings of alienation and betrayal when managed care constrains patient-physician decision making by limiting treatment options. These dynamics can lead to identifiable transference reactions and, in turn, to physician countertransference. Psychiatrists can do much to ameliorate these potentially destructive dynamics both as treating therapists and as consultants to general physicians. Indications for consultation or intervention are analyzed and specific clinical strategies to enhance the patient's decision-making capacity throughout the introductory, ongoing, and termination phases of the treatment alliance are reviewed.

Introduction

Psychiatrists directly face the challenges posed by the changing economic organization of health care, which brings approaches to health-care delivery that are experimental departures from traditional clinical values. These include the determination of “medical necessity” by third parties, a lack of choice of personal physician, and a variety of new treatment programs as clinicians experiment to cope with the pressures of managed care. As the implications of managed health care are scrutinized, it seems useful to call attention to an aspect of the managed-care phenomenon that, although heretofore little discussed, is especially salient for psychiatrists. We refer to the sense of captivity -- of having been denied the right to choose one's health plan, treatment setting, or provider -- central to many medical and psychiatric patients' experience with managed care.

Psychiatrists encounter this issue in at least two ways. First, it may be the subtext for many referrals and consultation requests psychiatrists receive from primary-care physicians involving problems such as the physician's inability to act freely in the patient's interest within managed care. A consultation may be requested because of the physician's discomfort with this conflict of allegiances and/or with the patient's frustration, anger, or withdrawal. Second, similar questions arise when psychiatrists are the primary treating physicians for patients whose mental-health benefits are limited by restrictive health plans or by the lack of parity in coverage for the treatment of major mental illness. Thus, whether as a primary-care provider or as a consultant for other physicians, the psychiatrist needs to understand the changing dynamics of the patient-physician relationship as these are affected by lack of choice of personal physician and treatment plan.

Managed Care in the Clinical Microcosm

We need not belabor here the dissatisfactions with managed health care expressed by health-care providers and the public, the new ethical dilemmas posed for physicians, the erosion of public trust in medical institutions to which managed care has contributed, the added liability risks for physicians placed in a position of responsibility without authority, the growing effort to hold managed-care organizations (MCO's) liable for medical malpractice under the theory of respondeat superior (vicarious liability) and other legal doctrines despite the obstacle presented by the Employee Retirement Income Security Act (ERISA), and the various legislative and judicial remedies implemented or proposed at both the state and federal levels. Essential as these societal initiatives are, it is in the doctor-patient relationship that the alienation and mistrust brought on by managed care are manifested, as seemingly arbitrary decisions by remote case managers or claim reviewers undermine the integrity of the clinical decision-making process. Moreover, while reform proposals properly emphasize restoring patient choice (of health plan, of primary-care physician, of out-of-network specialists), there has been little analysis of the clinical consequences of perceived lack of freedom of choice on the part of patients and physicians in managed care.

Institutionalized Choicelessness

For various reasons, many people who join managed care organizations (MCO's) today feel they have little or no meaningful choice of health-care provider. Some work for employers who (like 30 percent of U.S. companies) offer only one health plan, or are limited to a spouse's health plan. Others cannot change their coverage because of preexisting conditions, financial limitations, or other constraints. Once enrolled in a plan, many are not permitted to choose their primary-care physician. Such lack of choice has been found to be a major determinant of patients' dissatisfaction with their health-care plan. Even those who theoretically could change plans may be, in their busy lives, simply overwhelmed by barriers of time, effort, or understanding. Moreover, this lack of freedom of choice may become salient only in retrospect when the patient suffers major illness, since people have a limited capacity to predict their preferences for freedom in a prospective manner. Although such barriers were not unknown before the advent of managed care, the domination of many health-care markets by MCO's has heightened their influence.

The feelings of helplessness and hopelessness associated with lack of choice have long been recognized as concomitants of serious illness. What is new is that the denial of choice has become institutionalized. The health-care system is being structured in a way that is detrimental to health insofar as the subjective experience of choicelessness, of captivity, is potentially a major mental health problem exacerbating both medical and psychiatric illness. Optimally, the solution lies in restoring the possibility of choice for patients and their families. While 'thinking globally' toward this end, psychiatrists and other health professionals need to 'act locally' by responding therapeutically to the patient who feels like a captive so that, in some critical respects, this patient can regain a capacity to choose.

The Dynamics of Clinical Captivity

To provide patients with the increased freedom which an alliance based on shared integrity can offer one needs to attend to dynamics that typically arise in the patient-physician relationship when that relationship is not voluntarily chosen.

Transference in the Captive Patient

Illness reinforces preexisting mental constructions, or schemata, by which one characterizes oneself as helpless and hopeless. Thus, the reality or threat of serious illness can bring about dependency along with a profound sense of helplessness and hopelessness. Diagnostic and prognostic uncertainty contributes to those feelings, as does uncertainty about the extent to which the illness will close off life's possibilities. Serious illness represents a threat to the patient's control and ability to make choices; an effective clinical response often depends on mobilizing and enhancing the patient's ability to choose wisely from available alternatives. Tragically, an inability to choose where and from whom one receives medical care can intensify the emotional paralysis brought on by illness.

One is made doubly vulnerable when illness is compounded by an actual or felt inability to escape from the authority that dictates one's health-care decisions. This vulnerability begins with blind optimism and trust in the future while one is healthy, only to become blind pessimism and mistrust in the midst of illness and the potential for tragic outcomes. Since memory and identity are affect-dependent, both personal memory and history may be revised by the suffering patient to reflect a narrative consistent with the experience of virtual captivity. Even a person who was making a choice when signing up for a health plan may feel coerced and powerless about that selection after illness has struck.

The more helpless and hopeless one feels, the more one wants to find a sympathetic figure to whom one can attribute life-saving omnipotence and omniscience. Thus, the "captive" patient's intensified helplessness in the face of chronic illness can amplify preexisting, wish-driven perceptions of the doctor as omnipotent. This is an exacerbation of the normal process of transference, by which the ill, frightened patient seeks comfort by wishing the doctor to play a protective, ideal parent-like role. Disillusionment may set in when the physician is rendered powerless to implement clinical recommendations and protect patient choices under managed-care pressure. Even prior to the initial doctor-patient encounter, the patient may already be disillusioned, seeing the physician either as a representative of an indifferent, exploitative system or as a poor substitute for the physician, real or ideal, whom the patient trusted before managed care imposed a "gatekeeper." Such negative transference makes the formation of a therapeutic physician-patient alliance highly problematic.

Countertransference in the Captive Physician

The emotional dynamics of transference in the face of illness are predictable ones that a physician regularly encounters and, by being psychodynamically informed, can help the patient work through. Normally, the physician is encouraged to empathize with unrealistic wishes in order to help the patient put those wishes into a more realistic perspective. Such a perspective includes realistic acknowledgment of uncertainty, shared in a supportive patient-physician alliance. However, just as a sense of clinical captivity (i.e., a doctor-patient relationship that is not voluntarily chosen) can amplify the patient's transference reactions, so it can amplify the physician's defensive countertransference reactions.

Withdrawal from clinical engagement on the physician's part can be as much a source of misalliance as the patient's disruptive transference. The human tendency to forget, to look but not see, to deceive or anesthetize oneself as a protection against anxiety and pain is not limited to patients. The physician may be reacting to the patient's frustration and rejection of help; having to treat someone who doesn't want to be there can make the physician, too, feel like a captive. The physician's ability to help may also be limited by denial or rationalization of a constricted employment situation, decision-making impotence in the face of bureaucracy, or ethical qualms about participating in such a system.

Caught in a crossfire of demands and disapproval from the patient and the MCO, the physician understandably (though not necessarily consciously) may feel powerless to provide high-quality, ethical care. Even while health plans are eliminating "gag rules" prohibiting physicians from discussing treatment alternatives not covered by the plan, physicians may gag themselves, maintaining silence with the rationale that "I don't want to raise the patient's expectations." Or they may protect themselves by presenting a dark picture that undermines patients' hopes, as in what has been approvingly termed "hanging crepe," for the purpose of malpractice prevention.

Indeed, punitive profiling practices can function as implicit "gag rules" when they penalize physicians for hospitalizing patients, or even for requesting approval for hospitalization when such approval is subsequently denied. Such threats to a physician's continuing certification and ability to practice can compromise clinical judgment as well as any meaningful informed-consent process. Almost invariably the physician will err on the side of not recommending hospitalization, or of failing to explore and address patients' expected initial resistance to hospitalization under the pretext of respecting gravely impaired patients' uninformed “choices.” With such abuses of physician profiling, some MCO's are exerting a degree of control over physicians comparable to that exerted by training programs over residents, but without the same legal accountability.

Pressured physicians may excessively limit time spent with patients, subject patients unnecessarily to triage decision making, blur the distinction between "clinically contraindicated" and "medically unnecessary," or focus on costs to the exclusion of benefits. In such an institutional atmosphere, physicians and the organizations that employ or reimburse them may buy into short-sighted notions of conservation of resources and overly concrete, readily measurable “medical” benefits. Often overlooked by this mindset are the costs of incomplete treatment and the intrapsychic and psychosocial benefits of optimal treatment that considers the patient's overall well-being and life functions.

One example of the seductively simplifying style of decision making that grows out of clinician countertransference in managed care is the convenient assumption that "less is better" when it comes to end-of-life care. This bias, in which humane considerations appear to align themselves conveniently with economic ones, can lead clinicians to bypass the hard work of communication needed to elicit and understand the deeper intentions of patients and families. In this perilous arena of advance directives and "do not resuscitate" orders, economic considerations can exacerbate an institutional atmosphere of pessimism and ageism that can move the patient, family, and physician toward giving up prematurely, sometimes in the name of patients' rights. Elderly patients already depressed as a result of their illness, or those with chronic, socially stigmatized illnesses (e.g., AIDS, alcoholism, or schizophrenia), are especially vulnerable in such a negative atmosphere to simply going through the motions of informed consent. The kind of informed consent obtained when patients sign "living wills" while alone and bereft of all hope of care is neither adequately worked through nor truly voluntary.

Feeling distant from patients who did not choose them, conflicted about whether their primary allegiance is to the patient, the MCO, or their own economic and professional survival, physicians can inadvertently abandon their fiduciary duties to the patient. When the doctor-patient relationship is held captive to economic and organizational interests, managed care-driven clinical practice can iatrogenically undermine the effectiveness of the doctor-patient alliance, even within psychiatry itself, as a protective factor in the bearing of uncertainty and grief. The consulting or treating psychiatrist can help repair that alliance by enhancing physician awareness of both the transference and countertransference.

Indications for Psychiatric Consultation

A psychodynamically informed perspective and psychiatric consultation may be useful when the effects of lack of choice in managed care are themselves damaging to the patient and/or when they interfere with treatment and prevent optimal clinical resolution of the illness. When this alienation is especially severe, clinical and risk-management interventions including psychiatric referral of the patient as well as consultation for the physician may be called for. Examples of how a patient and/or physician may benefit from a psychiatric perspective involve maladaptations to choicelessness mediated by both patient transference and physician countertransference.

Patient Transference and Psychiatric Sequelae

The stress of illness often reveals aspects of an individual's character that we would not otherwise see. Under the added stress of denial of choice in medical care, the patient's emotional reactions (situational as well as characterological) to serious illness are likely to follow a downward spiral of despair and fear. Such reactions may, of course, be exacerbated by preexisting psychopathology. More commonly, the abrasions of managed care increase the likelihood of psychiatric comorbidity with threatening or chronic physical illness. Patient suffering can present in many forms, including the following:

Depression: Often a concomitant of chronic illness, depression can be intensified in managed-care situations by a lack of freedom of action. The patient's depressed mood then feeds back into a cycle of "learned helplessness" compounding the paralysis of reasoned decision making. Patients suffering from such helplessness may often say, "I'd just as soon be dead," rather than acknowledge their experience of a dual loss of control, both from illness and from the social context of restricted care choices.

Post-Traumatic Stress Disorder: The helplessness brought on by life-threatening illness can precipitate various reactions along the traumatic spectrum, up to and including Post-Traumatic Stress Disorder (PTSD). In a managed-care context, the helplessness that is a hallmark of the DSM-IV criterion A of Post-Traumatic Stress Disorder can be magnified, and the risk of a PTSD-like reaction thereby increased. An example of such a reaction is the previously traumatized patient (such as an elderly survivor of the Holocaust) who, when physically ill, presents by saying, "I feel like it's happening all over again."

"Sick role" adaptation: Without a supportive physician with whom the patient can share traumatic events, the patient may become preoccupied with those events. The patient may obsessively dwell on and magnify the details of the illness, or may transfer (inappropriately and in a manner disproportionate to any actual impairment) feelings of dependency into a chronic "sick role." This role can impose an undue burden on both family and work-related systems. Hopelessness, in the form of "I will never be whole again," is a typical reaction in this context.

Chronic pain: Conditions such as arthritis bring chronic pain and decreased physical mobility. Lack of choice of health-care provider increases the likelihood that the patient will experience these consequences with an attitude of surrender, concomitant with dependence on addictive medications, as a substitute for genuine acceptance, accommodation, and adaptation designed to minimize functional impairment. A multiplicity of pain symptoms can be amplified in this way.

Exacerbation of Substance Abuse and Dependence: The anxiety and pain accompanying chronic illness, at best difficult to manage, become more difficult when managed care puts the primary-care physician under added time pressure. Given patients' tendency toward self-medication in reaction to the helplessness of virtual captivity, the search for a quick fix with benzodiazepines and opiates, together with inadequate monitoring by a physician whose attention is too thinly spread, amounts to a recipe for the overuse of potentially useful pharmacological agents or nonprescription substances such as alcohol. "Can you give me something?" is a request increasingly made at the end of a rushed appointment by a patient who feels like a captive.

Conversion reactions: The delayed access to effective treatment that can occur in managed health care is another risk factor for psychiatric comorbidity secondary to the trauma of acute illness. For example, when someone who has been injured is initially denied access to transportation, an emergency-room visit, or relevant services such as diagnostic imaging until the condition becomes life-threatening, the delay itself can have a profound impact, not only physical but psychological, on the person's recovery. When, for example, a young child was injured in an accident, her parents were reluctant to call an ambulance because they had previously been chastised for 'unnecessarily' calling an ambulance for an injured sibling. Instead, they called the pediatrician, who (they reported) told them that they should drive her to his office instead. Subsequently it was discovered that the child had a broken neck, possibly exacerbated by the pediatrician's manipulations during examination. In a complicated course of treatment, which included surgery to stabilize the fracture, the patient developed a psychogenic paralysis, or conversion reaction. Given her previous experience, she had lost the requisite trust in medical authorities. Not surprisingly, she did not respond to supportive treatment for conversion in traumatized adolescents -- namely, reassurance from medical authorities.

Physician Countertransference

Consultation may also be indicated when the physician fails to acknowledge that the context of care is not of the patient's (and perhaps the physician's) own choosing. Signs that the physician is looking away from this critical dimension of the clinical situation include psychological defense mechanisms (e.g., denial, repression, dissociation, reaction formation) and evasive behaviors such as victim blaming or an involvement in reimbursement struggles to the exclusion of clinical care. A psychiatrist can alert the physician to the attitudes reflected in distancing rationalizations (or, at the other extreme, expressions of overinvolvement). Although analysis of transference is part of the daily practice of psychodynamically trained psychiatrists, they still can benefit from considering the influence of the current climate on their reactions to patients.

Common expressions of countertransference may be seen in statements such as the following:

Either extreme of overidentification with the aggressor (managed care) or with the victim (the patient) may call for intervention to help restore the physician's perspective. When the physician joins the patient in a folie a deux (either overly aggressive or overly passive), the patient's clinical needs go unmet. These defensive maneuvers stand in the way of forming a working alliance to confront the reality of the situation through treatment planning, problem-solving, reframing, and augmenting available resources.

Clinical Interventions

How can a psychiatrist work with patients and physicians to restore a sense of choice and, as much as possible, the reality of choice, to people who may view the physician and health-care system more as captors than as healers? Practicing in a time- and resource-restricted environment, physicians and other clinicians need to do all they can to make affective contact with patients so as to create provisional alliances even when the time and ongoing involvement usually required for alliance building are not available. Such alliances offer the best hope of engaging and, if necessary, rebuilding the patient's decision-making competence at the emotional as well as rational level. Psychiatric consultation is a critical resource for sensitizing practitioners to these needs and helping them apply the relevant clinical skills and attitudes.

To suggest practical guidelines for managing the clinical process with the patient who feels like a captive is not to acquiesce in the present system or to deny the need for collective action to change that system. Rather, it is to show how psychiatrists and other physicians might transform the system in the course of their daily work with patients. With a carefully considered clinical response to a patient's sense of captivity under managed care, the physician can enact and model the desired reforms within the microcosm of a one-to-one relationship, while providing the ethical, compassionate care patients need even under unfavorable conditions.

The goal for the physician is to maintain a primary focus on clinical concerns even amid obtrusive monetary and bureaucratic concerns. While the consulting psychiatrist can provide short-term crisis intervention in the physician-patient relationship, the psychiatrist's larger contribution lies in translating the concept of a therapeutic alliance to the general medical setting. To create a space to move from the experience of captivity to choice, the physician can be encouraged not to lose sight of either the external economic reality or the patient's internal reality. With the patient who has a chronic illness, the physician may have -- or be able to create -- the opportunity to build an alliance over time, one that has a beginning, middle, and end. Using the following guidelines, psychiatrists and other physicians can respond therapeutically, in each of the three phases of the relationship, to the lack of choice the patient experiences.

Phase 1: Introduction

The extent to which many a managed-care patient feels like a captive may not be evident in the initial visit. Some people are too alienated or intimidated to voice their concerns about managed care in the doctor's office -- although they will do so in a Harris Poll. Indeed, a patient who has delayed or avoided seeking medical care may be expressing the kind of disaffection from the health-care system that non-voters feel toward the government. The physician needs to be alert to implicit as well as explicit statements -- for example, when the patient lashes out at the receptionist for no good reason.

The physician's challenge is to find appropriate ways to let the patient bring out into the open any reservations he or she may have about changing providers. Care should be taken to avoid a provocative or accusatory tone. Too pointed a question may sound more like an expression of the physician's anger at feeling like a captive or defensiveness over the patient's anticipated rejection.

The informed-consent process provides a ready opportunity to anticipate possible reimbursement problems. When the patient has not freely chosen the provider, the legal requirement for informed consent must be scrupulously adhered to, so that the patient's knowing, voluntary choice is demonstrated in a clear and convincing manner. Beyond that, as stated in a recent court decision , there is an emerging legal requirement that the patient give informed consent to the economic as well as clinical dimensions of treatment. That is, the physician needs to inform the patient from the beginning about economic and institutional constraints that may limit decision-making options. In the course of this dialogue, the physician can observe the patient's reactions as well as look for objective indicators that the patient is in a captive, helpless position (e.g., the patient may be stuck in a job with an unsatisfactory health plan).

The informed-consent dialogue also offers an immediate opportunity to involve the patient in treatment planning, clinical and economic, which can lead to the patient's exercising some control in a framework of shared responsibility. Toward this end, it is unrealistic to pretend that problems can be resolved all at once. Deferring further discussion to the next visit sets a tone for an alliance involving continuity, mutuality, and reasonable limits. Such an alliance, confirming the patient's power to act responsibly, is an antidote to helplessness and anxiety as well as to the narcissistic entitlement often encountered as a response to post-traumatic feelings.

When exploring treatment alternatives, the physician can be encouraged not to restrict recommendations a priori to those that are covered, swearing oneself to secrecy out of fear the patient will be disappointed. Rather, the physician can honestly describe treatments that may not be reimbursable. In this way, the physician establishes the doctor-patient relationship as a place where the patient's preferred options can be taken seriously, even if it may be difficult or impossible to implement them. While outwardly deprived, the patient is still free to express and act on attitudes ranging from acceptance to opposition and to enlist the treating physician as an advocate.

Phase 2: Ongoing Care

Treatment should proceed with as much continuity as possible, in a longitudinal rather than episodic manner, with the patient involved throughout in treatment planning. As the patient's needs become defined, the physician reviews with the patient what stance to take toward managed-care treatment restrictions in light of the patient's evolving attitudes and preferences. As the physical illness or its psychiatric sequelae respond to treatment, the patient's freedom can increase. For example, a person with multiple sclerosis may learn to reduce the stress that precipitates the symptoms of this condition, or else may work on his or her reactions to the symptoms. The implications of a deteriorating condition must also be addressed. It is important to distinguish between limitations (both those stemming from the patient's physical or emotional condition and those imposed by the health plan) that the patient can likely do something about and those the patient may be either unable or unwilling to confront. Such considerations are part of an educational approach to patient care that, according to recent research, physicians too often practice in an abbreviated manner.

The collaboration between patient and doctor may be well along when the denial of benefits, on grounds of "medical necessity," for a course of treatment they have together chosen triggers a crisis both for the treatment and for the relationship. To help the patient avoid feeling trapped and disillusioned at such a difficult moment, it is advisable for the physician to avoid immediate termination and make every effort to continue the relationship, even on a less than ideal basis. As one way of doing this, the consultant might suggest that the physician work with the patient on an appeal, requesting and then providing information for the independent review of denial of benefits that (it is hoped) will ultimately occur -- as mandated, for example, by recent Connecticut legislation. It is also useful not to take "medical necessity" in any given case as mechanically determined by a guideline, but to explore what any diagnostic or therapeutic option actually means to a patient, as well as in the context of a broader consideration of equitable distribution of health-care resources. There may often be multiple and conflicting guidelines, differing interpretations of the application of any given guidelines to an individual case, and/or a failure to consider the impact of denial of benefits not only on the patient's physical but also mental health. Each of these limitations can justify a continuing attempt to resolve differences through dialogue with the MCO, or can lead to a successful independent appeal.

In the process, the physician is cautioned about falling prey to the triage-like mentality that can accompany the determination of "medical necessity," distorting normal prioritizing into a "do or die" imperative. It is a gross oversimplification to conceive of medical necessity as a diagnosis of exclusion, whereby medically indicated alternatives are ruled "medically unnecessary" unless no alternative treatments are available. A true determination of medical necessity involves weighing benefits, risks, and costs of alternatives along multiple dimensions. If respecting patient choice has therapeutic value, then that benefit needs to be factored into the decision, so that additional weight is given to patient preferences.

Throughout the course of treatment, the physician should remain available to help the patient consider the life choices that chronic illness periodically poses. Such guidance can include helping to wean the patient from an especially restrictive managed-care plan. For example, the patient may feel stuck in a particular job and its benefits package because of a chronic medical condition that limits work options. As treatment progresses, the patient may be able to change jobs or to find a more flexible health plan. Alternatively, a family member may change jobs to obtain better health-insurance coverage, or the physician can explore with the patient and family their willingness to consider the use of their own resources to pay for those services provided on an out-of-plan, higher-deductible basis, or else for those services which are helpful but not covered. In exploring such changes, the physician needs to consider any appearance of conflict of interest, seeking consultation to work through whatever ethical and alliance concerns may arise.

Phase 3: Termination

Termination of the doctor-patient relationship may occur because of life circumstances, cure or alleviation of the illness, or the patient's death. In addition, the patient may choose to transfer his or her care to another physician, or the MCO may drop the physician from its panel of providers. Of course, patients have died or changed physicians long before the intervention of managed care. However, the experience of these events may be influenced by the managed-care atmosphere. Some patients act out their frustration at managed-care restrictions by firing their physicians. For the dying patient and his or her family, grief and anger may be exacerbated by the belief (realistic or not) that treatment choices withheld by the MCO might have saved the patient's life.

When termination is necessitated by the patient's anticipated death due to illness, the physician can help the dying or terminally ill patient face the end of life realistically, rather than with cynicism or pessimism. The writings of Viktor Frankl about the Holocaust testify to his ability to help others find meaning, perspective, and humor -- that is, find something to live for -- amid the worst of tragedies. Still, there is a fine line between giving up and maintaining hope, however limited. Now as before, while conveying a realistic sense of the limits of his or her ability to help the patient, the physician gives assurance of his or her continuing presence in a supportive alliance. This assurance addresses the dying patient's fear of abandonment, which can be especially severe in patients who witnessed a relative die neglected in a nursing home and can be further intensified by managed-care pressures.

When the patient transfers to another care provider, the consultant can suggest that the physician review with the patient what choices they have made together, what other choices they might have made, and what role managed-care pressures may have played in their decisions. The physician then makes the referral, leaving the door open if the patient wishes or needs to return. Notwithstanding the patient's voluntary decision to terminate, the physician can confirm the meaning and value of their relationship by making clear that he or she will hold the patient in memory and will be open to resuming treatment if the patient makes that choice.

A physician whose contract is terminated by an MCO can avoid abandoning the patient by coordinating the transfer of care (including the transfer of records with the patient's signed release) to the patient's new physician. At the same time, the physician can be encouraged to support the patient's interest in opposing the involuntary termination.

Conclusion

We recently passed the fiftieth anniversary of the promulgation of the Nuremberg Code in the trial of Nazi doctors after World War II. The Code, consisting of ten principles for the conduct of medical experimentation on human subjects, begins with the statement, "The voluntary consent of the human subject is absolutely essential". The Nuremberg Code was developed in response to medical-experimental atrocities committed against people who were held captive and deprived of the most elementary human rights. However, its fundamental principle, in the words of the ethicist and psychoanalyst Jay Katz, applies across the board to "vulnerable patient-subjects who in their quest for relief from suffering may be readily inclined to place their trust in physicians, either in therapeutic or experimental settings."

It would trivialize both the Shoah and managed care to draw facile equivalences between the ethical horrors of the former and the ethical dilemmas of the latter. On the other hand, we should not turn a blind eye to the lessons history has taught, even if the circumstances of the teaching were very extreme. A recent commentator has noted that managed care appears to be subjecting whole populations to medical experimentation without consent, public review, or accountability, and with potentially large negative consequences for the patients involved. Even if one would not characterize the changes brought by managed care as experimental, this broader application of the Nuremberg Code would still extend to populations that experience captivity in that their health-care choices are either formally and involuntarily restricted, such as prisoners, or for all practical purposes so restricted. By placing the clinical implications of managed health care in this broad moral and legal framework, we can apprehend the true dimensions of physicians' and patients' experience of managed-care "captivity" and treat it with the seriousness it deserves, both in the macrocosm of public policy and in the microcosm of clinical intervention.