Is it unethical for physicians not to consider costs? – revisited

A few months ago, I commented on the new ACP manual of ethics for physicians. I had concerns about some of the language, specifically with respect to the 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.

Most of my concerns center around the concept that to be ethical, a physician has to focus so largely on the financial health of society when treating an individual patient. I just wasn’t so sure that was a good idea. The resources of society are important, and people do need to consider them, but those might be the primary focus of someone like me, for instance. When a doctor is treating an individual patient, we want them to be concerned with the needs of that patient, totally. I questioned whether we might be better served by physicians focusing that way, leaving others to focus on the societal level, with balance achieved between the two.

I also objected to the word parsimonious, but that’s another story.

There was a recent article in the NEJM entitled “Cents and Sensitivity — Teaching Physicians to Think about Costs” that’s making me rethink my position a bit. It begins by explaining that for a long time, physicians have been taught to develop as broad a differential diagnosis as possible when seeing a sick patient. We do this because we want to miss nothing. But working up such a differential can be expensive. So physicians might need to consider their role in the cost problem. Then, they run through some competing schools of thought on this, many of which we’ve discussed here previously.

But they touch on a point I had not considered before:

Yet some physicians now believe that considering cost serves not only the equitable distribution of finite services, but also the real interests of individual patients. Medical bills, after all, are among the leading causes of personal bankruptcy in the United States. When Neel Shah was doing his surgery rotation in medical school, an uninsured patient in the hospital slipped and fell on her way to the bathroom. She was not presyncopal, did not hit her head, and explained that she had tripped. Because the fall was unwitnessed, the resident ordered a head CT. When Shah suggested that the test was expensive and medically unnecessary, he was chided by the nurse and house staff, who retorted that cost was irrelevant. Shah realized that those around him seldom considered that their clinical decisions would translate into bills for their patients. He sees such consideration as ethically imperative.

I can’t count the number of times I’ve complained it’s wrong to consider care, especially care in the ED, “free”. The hospitals will collect, even if you are of limited means. But I forgot that in pressing ahead, no matter what the cost, we could be doing individual financial damage. Patients are on the hook for what we spend, and we likely should consider the economic harm to them, even if we’re not explicitly worrying about society as a whole.

The article is short and totally worth your time. Go read.


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