FIG1 Thirty years ago, when
psychiatrist James Sabin, M.D., joined Harvard Community Health Plan (HCHP),
the organization was in the vanguard of a movement its advocates hoped might
become a model for a reformed American health care system.
James Sabin, M.D.: "What attracted me to psychiatry in the first
place was that it seemed like an area where one could help individuals make
the most of their lives and at the same time engage with the deepest and most
central existential issues at the individual and societal
Photo: Courtesy of James Sabin, M.D.
Along with Kaiser Permanente and Group Health Cooperative of Puget Sound,
HCHP pioneered a vision of prepaid medical care within a staff-model HMO,
seeking equitable and ethical allocation of resources for a defined
It was a vision that challenged the dominance of the model of
private-practice, fee-for-service medicine and offered a remedy—so its
adherents believed—to the idiosyncrasies and inequities (and the rising
costs just then making themselves felt) inherent in that model.
In time, Sabin would become associate medical director at HCHP, and then
associate director of the health plan's fledgling teaching program.
"I thought an HMO-based teaching program ought to address the
question of how can societies best address the issue of providing access
to—and at the same time setting limits for—a fundamental human
good? And how can that process be done in a way that is clinically informed,
ethically justifiable, and socially acceptable?"
Today, the notion of prepaid managed care as the antidote to America's
health care problems appears to have been sidelined by the anti-HMO"
backlash," and HCHP has separated into Harvard Vanguard Medical
Associates, a clinician-governed multispecialty group practice, and Harvard
Pilgrim Health Care, a not-for-profit health plan.
But the questions that intrigued Sabin then still animate a career devoted
to exploring how medical resources can be ethically allocated across a
population. And he has continued to expound the founding visions of managed
care, while physician colleagues have come to regard "ethics" and"
managed care" as mutually exclusive.
As director of the Harvard Pilgrim Health Care Ethics Program and
co-founder of the Center for Ethics in Managed Care, sponsored by the
Department of Ambulatory Care and Prevention and Division of Medical Ethics at
Harvard Medical School, Sabin is responsible for a nationally recognized,
Sabin leads periodic meetings of Harvard Pilgrim's Ethics Advisory Group,
which includes members, employer representatives, clinicians, and staff, and
helps provide an "ethical compass" for the company's business and
clinical decisions. In 2004 the group suggested principles and guidelines on a
number of important issues facing the health plan, including the risks and
advantages of bariatric surgery, the use of preexisting-condition exclusions
in benefit plans, the movement toward increased patient cost sharing and"
consumer-directed" plans, and the proper collection and use of
data that identify members' race and ethnicity in programs intended to reduce
disparities in health care.
Setting Limits Fairly, written with Norman Daniels, was published
by Oxford University Press in 2002. No Margin, No Mission: Health Care
Organizations and the Quest for Ethical Excellence, written with Steven
Pearson and Ezekiel Emanuel, was published by Oxford University Press in
In 2002 Sabin received the American Association of Community Psychiatrists'
Moffic Award for Ethical Practice in Public Sector Managed Behavioral
Throughout, of course, Sabin has always treated patients with mental
illness, and he emphasized that his interest in organizational ethics and his
training in psychiatry are far from antithetical.
"I think our profession has an inherent connection to the domain of
ethics," he told Psychiatric News. "In our clinical work
with patients, we are hearing in deep ways about values, and our role is to
understand and bring about constructive movement for individuals, families,
and groups. So as clinicians we are dealing with the core activities that the
field of ethics deals with."
Much of what Sabin means when he refers to ethics is centered on the
understanding that health care is a finite resource, and hence one that is
rationed—either fairly or unfairly. As he wrote in Setting Limits
Fairly, "Because resources are limited, all societies must set
limits to care and establish priorities about how resources will be
used—whether they acknowledge doing so or not."
It is a notion that has not found easy acceptance in America, and thus it
may not be surprising that Sabin's collaborative work with Daniels has been
more widely received in Europe than in the United States.
"For some, rationing means taking an otherwise healthy person and
turning off the ventilator," he told Psychiatric News."
But what it really means is hard-nosed attention to the most
cost-effective way of providing care. That's the thing that needs to be done
day in and day out—making difficult decisions about whether a small
marginal benefit warrants a significantly larger cost.
"By and large we have avoided those questions at the program level,
with the exception of a number of Medicaid programs and organizations like
Kaiser, which are explicit about looking at the evidence and making decisions
about how to practice."
Thirty years ago, he said, the insurance industry largely performed a"
pass-through," or middleman, function, paying hospitals and
physicians for services rendered to enrollees. When costs began to escalate,
however, policymakers expected insurers to take a more active role in making
determinations of value and worthiness of expenditures—a movement that
formed the basis for managed care.
But, Sabin said, insurers took on this task with "zero public
education about the need for managed care and zero political leadership in
articulating the underlying problems." And while there were
organizations that had decades of experience in ethical, population-based
health care, there were others that practiced what Sabin called"
1-800-Just Say No."
The result was an enormous backlash against managed care that tarnished the
Today, Sabin sees a "third wave" in the insurance industry
marked by the effort to pass decisions about limit setting down to the
patient, through higher deductibles and tiered formularies.
"We have essentially said for the moment that we cannot effectively
set limits in health care as a society, so we will ask individuals to decide
for themselves what is worthwhile through significantly increased
deductibles," he said. "Where this goes remains to be seen. On the
up side, some of the population may become much more discerning and thoughtful
consumers of health care, bringing about a kind of public education that the
political process has failed at abysmally.
"At the other extreme, people of limited financial means may simply
forego medically important care and risk a decline in well-being. If this
happens, their plight is likely to trigger a backlash against this
The American political process has failed in other ways to lead an informed
discourse about ethics and medical care, Sabin said. A case in point is that
of Terri Schiavo, which he called "a perfect storm for ethics and public
policy" because several factors came together in a way that led to a"
stunningly muddled" discourse.
"Part of it was the media's focus on a painfully bitter difference of
perspective within the family," Sabin said. "And part of it was a
political process that corrupted efforts to understand Ms. Schiavo's medical
condition, a process that went wildly out of control.
"One good thing perhaps is that it seems the public had a fairly high
degree of revulsion at the political posturing and showed good sense in
distinguishing between the tragic personal situation and the disgraceful
political maneuvering. But for the most part, deep moral issues got lost when
the political process picked up on the personal situation and exploited it for
partisan political gain."
Today Sabin is extending his interest in ethics and medical care overseas
to India, where he is working with colleagues investigating the ethical and
social aspects of the effort to roll out antiretroviral medicines for
The goal of the Values and Access to Medicines Project is to improve the
effectiveness and equity of international, national, and local programs that
deliver antiretroviral treatment for HIV/AIDS in developing countries. The
project builds on efforts to identify, in the context of the U.S. managed care
system, a systematic approach to values in the provision of pharmacy
Sabin said that although this new endeavor might seem to be a far stretch
from the practice of psychiatry, in fact it feels like familiar territory."
What attracted me to psychiatry in the first place was that it seemed
like an area where one could help individuals make the most of their lives and
at the same time engage with the deepest and most central existential issues
at the individual and societal levels.
"That's proven to be true," he continued. "In one sense
what I've done is unusual, but to me it feels almost like a linear application
of the core values and activities that psychiatry is all about."▪