as responsible for supportive end-of-life care—palliative specialists, hospice personnel, ethics consultants, chaplains, and others—may not always know whether they are fulfilling their responsibilities.

The concept of accountability also raises the question—"accountability to whom?" The health professions have traditionally defined their accountability with reference to those they serve (e.g., patients, students) and to their fellow professionals and the standards of performance they have collectively created. For more than a century, however, state and federal governments in the United States have been developing regulatory mechanisms to supplement or, in some instances, replace professional accountability. A recent IOM report defined public accountability for those serving Medicare beneficiaries as involving not only beneficiaries but also "the larger public as interested parties and taxpayers" (IOM, 1996b, p. 31). In addition, private organizations, including hospitals, health plans, and other organizations, have established mechanisms of accountability. As a result, any one clinician or health care organization may be accountable to multiple parties whose expectations may not be fully compatible.

A third question—"how are professionals and organizations to be held accountable?"—requires a complex answer that involves a mix of social norms, regulations, economic incentives, measurement tools, and information reporting mechanisms. The notion of accountability to one's own conscience and a recognized set of ethical standards (e.g., the Hippocratic Oath or one of its successors) is appealing because it implies an internalized, ever-vigilant control mechanism. It is also part of what defines and dignifies a profession. It likewise provides a basis for trust that patients' vulnerability will not be exploited by physicians and other health professionals for "power, profit, prestige, or pleasure" (Pellegrino, 1991, p. 80). External regulations, reporting requirements, and accreditation standards have a role to play, but the imposition of external rules and monitoring does not make up for a lack of trust or trustworthiness.

The "invisible hand of the market" is yet another mechanism of accountability that relies on decisions by millions of informed consumers (and their agents) that, in theory, reward good performers and penalize poor performers. In health care, making quality a meaningful factor in such decisions is, today, an embryonic undertaking in which the quality of end-of-life care is largely invisible. Price is a more easily understood and comparable variable and the extent to which purchasers actually consider quality in their decisions is controversial.

Quality of Care

The quality of health care should contribute to the quality of living and the quality of dying but, as noted in Chapter 1, it is not synonymous with

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