Over the past decade the restructuring of healthcare has resulted in the growth and development of managed care organizations (MCOs). Although this growth and development are well documented in healthcare literature, ethical aspects aren't. Thus, we conducted a qualitative study in which we interviewed 15 registered nurses enrolled in a doctoral nursing program in Virginia. We asked, "What do nurses perceive to be the positive ethical aspects of the restructuring of healthcare, in particular, MCOs?"

Let's "listen" to the voices of three study participants as they implicitly discuss the ethical principle of justice and MCOs:

We had a horrible system before managed care. We had patients who fell through the cracks constantly. We had inequitable distribution of resources like you wouldn't believe [horizontal ellipsis]We go to Congress every year and ask for a certain budget to pay for health-care; we have an obligation to keep that tax as low as possible.-Study Participant 8

There was a woman who was an amputee. It was only one leg that was gone just above the knee. She wanted her prosthesis changed. Well, certainly we could arrange that in town and get her fitted well. She found a place in Arizona that claimed to fit a prosthesis so that she could jump like Michael Jordan. And so my question to her was: "Before you had your leg amputated, did you ever jump like Michael Jordan?" And her answer was no, so I said no. I wasn't willing to do that because the additional money could go to someone else in need.-Study Participant 2

You just get people out there, who, with every little ache and pain, every little bump to the head, every little anything, want a referral to the specialist. Prior to managed care, this went on and created all the specialization. We don't need this in a lot of cases. What you need is good primary care. Expertise in primary care is being able to see hundreds of headaches, hundreds of things in children, and know which ones may be the brain tumor. But you don't turf all one hundred. You turf ten [of concern]. That's cost-effective healthcare. It's using the primary care system appropriately.-Study Participant 13

How did the preceding study participants view the ethics of justice within MCOs? Study participant 8 saw justice as judicious distribution and stewardship of federal tax dollars. Study participant 2 saw justice as need-based. Study participant 13 saw justice as both need-based and as judicious distribution and stewardship of healthcare dollars.

Questions for nurse managers

Here are five questions for you to ponder based on MCOs and the ethics of justice:

1. How have MCOs changed what constitutes justice in the delivery of healthcare?

2. What are positive and negative aspects of justice related to MCOs?

3. What are the ethical principles of justice underlying MCOs?

4. What constitutes judicious stewardship of tax dollars within MCOs?

5. What are pros and cons for need-based healthcare within MCOs?

Your answers to the preceding questions, as well as the degree to which you and other healthcare providers are committed to the ethical delivery of healthcare, speak the extent to which the healthcare system will be ethical, including the ethical principle of justice. How will you make a commitment to a just healthcare system within MCOs?