nsible for their patients, and modern economic arrangements have encouraged physicians to focus on their patients' welfare, virtually to the exclusion of costs or other competing considerations. Fueled by these economic and ethical factors, in turn, tort law has empowered the medical profession to define quality for legal purposesùto set the standard of careùand has required physicians to deliver a roughly uniform standard to all patients, essentially regardless of cost.
Recent economic changes now force reconsideration of this pattern. Arguably, physicians' mandate to deliver a lavish, highly interventionist quality of care is no longer economically sustainable, medically justifiable, ethically acceptable, or legally defensible. As third parties exert greater control over strained resources, it is no longer possible or plausible for physicians to command resources with just a signature. And as people who have been excluded from the health care system gain entry to it, defining quality strictly in terms of an individual patient's welfare, without regard to competing concerns or overall resource constraints, is no longer acceptable. A credible notion of quality in health care requires a more explicit recognition of economic limits and a more reasonable allocation of ethical, medical, and legal responsibilities. In the forefront of these changes, patients, who are not only the recipients but also the ultimate payers of care, must now participate actively in making the cost-value tradeoffs inherent in any new definition of quality.
II. THE QUALITY OF AFFLUENCE: MEDICAL, ETHICAL, LEGAL
The history of health care economics in the United States is amply chronicled.(1) Here we need only a broad outline to illustrate how the lavish health care funding of the past half-centuryùjust prior to recent years' panicky cost containmentùshaped our ethical, medical, and legal ideas about physicians' responsibilities. The next section examin...