Date of Award


Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)

First Advisor

Mary Olson

Second Advisor

John Culhane


In the 2000 case Pegram v. Herdrich, the U.S. Supreme Court decided that administrators of health benefits plans covered by the Employee Retirement Income Security Act (ERISA) of 1974 do not have a fiduciary duty towards beneficiaries when making "mixed decisions" involving treatment and eligibility components. This thesis, Rethinking Pegram: Why ERISA Health Benefits Administrators Should Have a Comprehensive Legal Requirement of Fiduciary Duty, challenges the Court's opinion on grounds of legal precedent and public health ethics. While the legal critique of Pegram is an elaboration of earlier scholarship, the public health ethics critique represents a unique contribution to the field.

The problem area that this thesis seeks to address is the conflicts of interest that arise under contemporary arrangements of managed care. Various gate-keeping schemes and financial incentives put physicians in a position where they can no longer solely consider the best interests of their patients. Instead, they must balance the needs of the individual patient against the limited resources for the entire patient population. In resolving this challenge, however, physicians receive little or no guidance from traditional ethical paradigms of medical ethics and bioethics, which were developed with dyadic relationships in mind.

A reversal of Pegram, or the de facto creation of a legal requirement of fiduciary duty for BRISA plans, would help to ameliorate this problem of dual agency and restore trust to the patient-physician relationship. This policy is justified along the four dimensions of public health ethics: the communitarian tradition and common good, scientific-based decision-making, social justice, and legitimate government intervention.

Open Access

This Article is Open Access

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