Box 3.

: Are the costs of improvement excessive?

• A health maintenance organisation in the United States considers investing in improvements in its system for caring for patients with AIDS. The vice president for marketing warns that such improvements may lead to selective enrolment of unprofitable members—namely, those with HIV infection. Is the organisation ethically bound to improve its HIV care, even if that may reduce its financial viability?
• The “improvement” principle states that improvement is a serious and continuing responsibility. The “balance” principle recognises the tension that may exist between the needs of individual patients and those of the population, and this principle should be considered if the investment might threaten services to other patients. The “safety” principle suggests that it would be wrong to retain a deficient system because avoidable harm could result. The “rights” principle means that it would be poor behaviour to seek to deny the right to health care by avoiding changes that might attract more patients. According to the principles, it would be wrong not to make the investment.