How should physicians respond to requests for nonbeneficial interventions?

In JAMA, Allan Brett and Laurence McCullough ask us to

consider an insured man with new-onset low back pain and no findings suggesting a serious disorder. He requests a magnetic resonance imaging (MRI) scan “to see what’s going on.” The physician should explain that MRI will not change initial management and that standards of care do not endorse MRI for the patient’s problem. Suppose the patient counters that he wants to get his money’s worth for his insurance premiums. The physician should reply that medical professionals must utilize health care resources responsibly and that the insured patient’s health care costs ultimately affect other patients. What if the patient offers to pay out of pocket? Even then, the physician should not order the scan: ordering it reinforces a habit of nondeliberative clinical reasoning and the mistaken idea that costs are irrelevant.

Is the physician exercising an appropriate role to promote parsimonious care? Brett and McCullough think so. This is obviously in conflict with consumer-directedness or patient-centeredness or shopper-empowerment or I-will-do-what-I-damn-well-please-with-my-money-ness.

Patient autonomy is often invoked to support patients’ requests for specific interventions. According to this perspective, patients’ preferences are always decisive because medical decisions reflect value judgments, and patients are always better suited to choose interventions consistent with their personal values than are physicians. However, this rationale is flawed. Distorting biases may influence a patient’s clinical judgment, and autonomous patients sometimes make decisions that confer no benefit or put their health at risk.

Using patient autonomy to justify acquiescence to patients’ requests for nonbeneficial services violates professional integrity. Professional integrity requires physicians to adhere to standards of intellectual and moral excellence. Physicians achieve intellectual excellence by submitting clinical judgment to disciplined, evidence-based reasoning. Physicians achieve moral excellence by protecting patients’ health-related interests as a primary concern, keeping self-interests systematically secondary. Commitment to professional integrity requires that physicians challenge requests for nonbeneficial interventions. For example, patients may derive subjective value from taking antibiotics for viral infections; however, such value is not decisive in the absence of benefit from the medical perspective. Over time, allowing patients’ demands for unnecessary interventions to trump careful clinical reasoning results in a nondeliberative, rote practice style that undermines clinical excellence.

Many will not find this argument compelling. Either you think medical science trumps patient autonomy or not. Some will think not. But there’s another perspective, not articulated by the authors. It’s most salient in the self-pay case. Imagine the patient, insured or not, agrees to pay the full cost out of pocket. In this case, only two entities matter, presuming externalities don’t exist or are insignificant. We have a buyer (the patient) and a seller (the physician). The transaction is similar to any other exchange of good or service for money. The exchange should be entered into by both parties willingly, voluntarily.

Now whose views should dominate? Does the patient have the right to the (nonbeneficial) care? Or does the physician have the right to refuse it? I think this case is perfectly clear. Each has the right to a veto. The physician need not substitute the patient’s values for his own. It’s his service and he has the right not to sell it. The patient has the right to seek another provider. He does not have the right to compel a sale.

If all nonbeneficial care were excluded from coverage, this is precisely the situation we would be in. It would be no different than many other non-essential transactions. There are many professionals who probably refuse work in their field they find objectionable or unethical for one reason or another. A construction contractor might not wish to build a dungeon. A tax professional my not want to perform certain “borderline” tax shelter maneuvers. I do not wish to sell my hair.

The customer is only always right if you want to make the sale. I see no reason why a physician must make every sale and especially when the intervention is not beneficial to health.

UPDATE: I see there is some confusion over what question I’m asking/addressing in this post. I can put it more simply this way: If a physician (reasonably) believes a treatment to be nonbeneficial, must she provide it anyway on request by a patient? This is a slightly different question than the authors I quoted address, and it has nothing to do with the precise treatment or the characteristics of the patient beyond those that inform whether the treatment is or is not beneficial in the mind of the physician.

AF

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