A different approach to integrating fairness with autonomy is to try to be as scientific as possible about medicine. The procedure was denied by the Kaiser Foundation Health Plan liver transplant advisory board because, the board reportedly said, the highly infectious disease would cause the transplant to fail and was therefore contraindicated. Mr. Barnett paid privately for the procedure and then sued. The Ninth U.S. Circuit Court of Appeals found in Kaiser's favor. Medical criteria, it decided, were a valid way to make medical judgments about efficacy and benefit.
Physicians are the appropriate people to make allocation decisions about such resources.
Trade-offs between the individual and the group have to be made, the court said, and providing benefits to as many plan members as possible was Kaiser's job, though it would be inappropriate to make medical decisions based solely on saving Kaiser money. Although this individual advocacy may run contrary to the details of the contract a patient or his employer signed and to principles of justice and population-based health, personal advocacy is still what individual patients expect. Whether they should expect that advocacy is a different, harder question. Physicians, ethicists and attorneys are beginning to address cases that shift the discussion from what a physician owes individual patients to his or her responsibilities to all managed care organization patients. Managed care organizations, for their own communities and at their most noble, can answer.