Quality and cost: choices and responsibilities.

Practitioners are at least obligated to provide the most effective care most efficiently. But when added benefits are small relative to added cost, practitioners may stop short of the most effective care in obedience to patient preferences. If payers impose a different standard of optimal care, I suggest that health care professionals will respond in one of three ways: oppose intervention, adopt the economic optimum, or take an intermediate position by accepting the payer's specification of optimal care but safeguarding the individual practitioner's role as an advocate for each patient and the profession's role as an advocate of its view of the public good.