• Is it unethical for physicians not to consider costs?

    The American College of Physicians has published their updated manual on ethics for physicians. I’m still wading my way through it, but on the whole, I’m impressed. Many of these types of documents get watered down by committee. This one, though, manages to make a fair number of declarative statements. Ezekiel Emanuel noticed the same in his accompanying editorial:

    However, what is truly amazing is that the Ethics Manual contains so many clear and specific recommendations. On execution, interrogation, and torture, the ACP Ethics, Professionalism, and Human Rights Committee is definitive and absolute. Indeed, it specifies not only negative duties but positive ones as well:

    Participation by physicians in the execution of prisoners except to certify death is unethical.
    Physicians must not conduct, participate in, monitor, or be present at interrogations. . . .
    Physicians must not be a party to and must speak out against torture. . . .

    I’m a little less impressed with their hedge when it comes to relationships and gifts from industry. Again, Emanuel agrees with me:

    Another section of the Manual that will probably generate debate involves physician–industry relationships. The Ethics Manual states that “[t]he acceptance by a physician of gifts, hospitality, trips, and subsidies of all types from the health care industry that might diminish, or appear to others to diminish, the objectivity of professional judgment is strongly discouraged.” Many will question why the ACP strongly  discourages such gifts rather than prohibits them outright. Indeed, if the gifts diminish or appear to diminish judgment, they must be prohibited to maintain the integrity of the physician and the profession.

    But the part that raised my eyebrows the most, and where I’m not sure I am in total agreement has to do with a physician’s responsibility to society:

    Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.

    I’m sure many of you are shocked by my concern with this statement. Let me explain.

    I talk a lot about the fact that we, as a society, need to think about cost-effectiveness if we are going to get a handle on the cost of health care. This means saying no to some treatments and tests, because we have to use health care resources responsibly. When I say such things, inevitably someone counters me by questioning whether I would feel the same way if my child’s life was on the line.

    The answer is, of course not. If my child’s life were at stake, I would fight tooth and nail to get anything – and I mean anything – to save him or her. I’d do it even it it cost a fortune and might not work. That’s why I don’t think you should leave these kind of decisions up to the individual. Every single person feels the way I do about every single person they love, and no one will ever be able to say no. That’s human.

    Similarly, I don’t think that it’s necessarily fair to make it a physician’s responsibility. I also want my child’s doctor to fight tooth and nail to get anything that might save my child. Many times, physicians have long-standing relationships with patients. Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.

    So whose job is it? Well, mine for instance. That’s what I do as a health services researcher. That’s what policy makers should also do. That’s what we, as society should do. There are people who should have the responsibility of debating and deciding what is and is not cost-effective. They should have to make decisions that may be unpopular, and they should have to face the wrath of those whom the decisions impact. But there’s no good way to make it an individual’s responsibility to determine what is cost-effective for their child. That hardly seems “ethical”. I’m not sure asking doctors to do it is such a good idea either.

    But ethics is something we can and should debate. I hope we can have a robust discussion about this.

    UPDATE: Paul Kelleher thinks the ACP and I are more in agreement than I thought. I’m still not sure. I think some, if not many, will read the manual as I did. If the ACP and I are in full agreement, I with they had been clearer.

    UPDATE #2: I’m surprised by a few people who are really, really working to say that I’m twisting the ACP’s words. I’m not. And I don’t have to be “careful”. The ACP chose to work the words “cost-effectiveness” and “resources” into a manual of ethics. I’m bringing up a point of concern with that. I’m not condemning the ACP, nor the people who worked on the document. It’s their job to make things clear when they are telling physicians how to be ethical. If I’m misreading it, they might want to reconsider their language. If they agree with me, there were, perhaps, better ways to say what they were trying to get across.

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