The Quality of Care: How Can It Be Assessed?

To the Editor. —

Dr Donabedian¹makes an ambiguous assertion when he claims that the technical quality of the health care provided by physicians is based on the health outcomes they achieve in patients, while at the same time acknowledging that physicians are obligated to serve the best interests of patients. Problems ensue when one argues that health outcome is the primary grounds on which to define quality and that medicine allows concerns beyond health. The problem is that the outcome approach to quality binds medicine to the goal of opposing disease, despite the fact that diseases can be preferred to health. For example, some patients in rational fashion choose the drawbacks (including side effects) detrimental to health brought about by the oral contraceptive to have greater autonomy, freedom to enjoy career choices, preferred spacing of children, and other benefits. Consequently, Dr Donabedian cannot hold that the goal of