• Is it unethical for physicians not to consider costs? – ctd.

    I’ve been surprised by some of the pushback against my post on the the ACP manual of ethics. So I want to take some time to explain myself further. Let me make a few points:

    1) One of the first things I learned as a writer is that if someone misunderstands what I’ve written, my first thought should not be that it’s the reader’s problem. I should always consider that I could have made my point better. So please stop telling me that I misunderstood them and to stop misunderstanding. I’m an engaged and intelligent reader, and if I didn’t get their point, I think they might want to make things clearer.

    2) I did not pull a few sentences out of context. The text I drew from was a section entitled “The Ethics of Practice”. It’s page 86-87. I even quoted from a highlighted Box (#4), so they wanted that text to stick out.

    3) This is a document about ethics. I take that very seriously. This is not an editorial, nor an exhortation about how physicians need to think or act. It’s not a comment about society or how we should make policy. It’s a manual telling physicians how to be ethical. The ACP chose to put the words “cost-effective” in an ethical document, in a section specifically dealing with clinical practice. Maybe that was the right decision. I’m not sure. But I think it’s worth discussing, and so I did.

    4) I don’t think it’s a bad idea for doctors to consider cost-effectiveness when they talk to patients. I think it’s fine for patients to see that some treatments may be a waste of money, and they might want to save that money. But I’m not sure that I think it’s as great an idea for doctors to consider “health care resources” in the same way. I’m just not as comfortable with that. At least, not when we’re talking “ethics”. Is a physician who advocates for a treatment that’s not cost-effective acting unethically? Again, I don’t think that’s what the ACP intended. But most physicians likely won’t spend the time to read the whole document. Most won’t even look at the highlighted boxes. But some will. And the word “parsimonious“, meaning “extreme unwillingness to expend resources” or “frugal to the point of stinginess” is right there. I’m not sure that was a good idea in a manual of ethics.

    5) I am a fan of the ACP. I don’t think badly of them. I don’t think they are evil or have ulterior motives. I’ve been a fan of theirs for longer than some of you have known who they are. And I’ll keep poking them with a stick. That’s how I show my love.

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    • “And the word “parsimonious“, meaning “extreme unwillingness to expend resources” or “frugal to the point of stinginess” is right there.”

      Inconceivable!

      (Is it possible that the authors didn’t really understand the true definition of that word… as in http://www.youtube.com/watch?v=G2y8Sx4B2Sk )

      • I think so — I thought it meant more like “careful not to waste money” and not the much more stringent meaning that it apparently has.

    • I was struck by the use of the word “parsimonious” as well. I believe that the ACP meant it in the philosophical, Occam’s Razor, sense, but perhaps their point would have been better conveyed if they said “efficient”.

      Your point about physicians’ roles is well taken. From the perspective of the system, we do want to influence practice patterns towards efficient care. But indeed, if it were my child, it’s very justifiable to want the physician to lean much more towards doing everything – for kids especially, because they have many potential years ahead in most cases, aggressive treatment can be warranted.

      There’s no easy answer, of course.

    • Aaron,

      I feel as though you have been unfairly criticized. This is, in fact, an important issue and I think you have been very thoughtful about your approach to it.

      I do think there is a “tragedy of the commons” issue here. Optimizing individual decisions can easily lead to a sub-optimal outcome for society as a whole. One of the ways to ameliorate this is for individual decision makers to take the global implications into account when making those individual decisions. I.e., I personally don’t think it is OK for doctors and patients to be focused totally on the case at hand in making these decisions. To say it another way, if we feel ourselves to be part of a community, we should include the community-wide consequences in our decisions. I hope that is what the ACP was driving at.

      And I agree that they didn’t remotely communicate this effectively.

    • You can’t divorce ethics from ownership. You can be as parsimonious as you want with things that you own without violating any ethical principles.

      Since physicians don’t own their patient’s bodies, or the assets used to pay for their care – they have zero right to decide that they’ll deprive patients of potentially beneficial care in the name of conserving resources that they don’t own.

      At the very least, physicians engaging in this behavior have an ethical duty to disclose the fact that they’re doing so.

    • “Since physicians don’t own their patient’s bodies, or the assets used to pay for their care – they have zero right to decide that they’ll deprive patients of potentially beneficial care in the name of conserving resources that they don’t own.”

      But that depends upon the context. In the case of a major natural disaster, for example, there will always be some form of triage.

      How far along that spectrum from natural disaster to everyday occurrence that “triage” occurs is, I think, a community decision.

    • If it’s my duty as a physician to look out for the well-being of my patient, then I think I should try to be aware of what the care I’m ordering is going to cost my patient and if it is going to be a financial burden for him/her (e.g. if they have a high-deductible plan or no insurance), especially if the service is discretionary, it’s a test that won’t change management, etc. If that’s the case, I think I should try to see if there are less expensive alternative strategies that are equally effective (e.g. generic medication rather than expensive brand name). Not only may this prevent financial problems for my patient, it also might make them less likely to forgo needed care because of cost.

      • And I absolutely, positively agree with what you say.

        My issue is point (4). I’m not sure how good an idea it is to say that for a doctor to be ethical he or she needs to be “parsimonoius” in their care while considering resources not of the patient, but of society.

        I think society needs to make those decisions, definitely. When you say something is part of being ethical, there is not a lot of wiggle room for the physician. I’m still not sure they made the best use of language here.