• 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.


    • Good points.
      I read your story about the lady who fell in the hallway with interest. And WHY did the nurses and house staff insist on a head CT? A potential lawsuit.

      Anyway, societies that have universal healthcare of some kind definately keep costs and benefits in mind as they tailor their systems. There just is now way around it.

    • I beleive we as physicians are responsible for the rising cost of medical care. We are the ones who write the orders. I have 3rd year students in my office regularly and we discuss this issue as regards to unnecessary testing. The response I receive is two fold; first they are taught “to not miss anything” no matter how unlikely it might be and the fear of being sued. As I explain to them the only factor to consider in ordering any test is will the result help me to take care of my patient better. If the answer is not yes it will then the test should not be ordered.

      David Porter

    • This almost reads like a parody of our increasingly technology-dependent society. Someone trips? Watchful waiting is one option, but we do a CT scan. They call that the technological imperative in medical sociology: if there is a high tech piece of equipment that can do the job, it must be used instead of anything else.

    • We always had to do everything for “completeness”. I still remember doing Brucella cultures on an inner city drug addict. Like that was going to yield anything. Anyway, the first part here is for docs to know what stuff costs. Not that many do.


    • Aaron, this is a terrific piece, and kind of tragic also. I have thought about this issue a lot.

      The best solution is what the great Dr. Robert Evans of Canada talked about 20+ years ago.

      Put hospitals on a global budget where there are no user fees. It is impossible to do a patient harm if the patient never gets a bill.

      This will NOT remove a debate about what tools to use for care.

      But the arguments — and they can be bitter in Canada — are between doctors and bureaucrats.

      One can argue that the benefits of high-tech care are so great, that if
      200,000 patients go bankrupt each year then that is the cost of progress. Hosoitals have over 30 million patients each year, so 200,000 is not a lot.

      The Canadian practice would seem to lean overboard to prevent financial harm to anyone. The result (at least we are told by Cato types) is that dogs get more MRI scans than humans.

      Anyways thank you for seriously raising the issue.

    • While I agree the physician’s duty is to his or her patient and not to society, evidence indicates that simple knowledge of the cost of care reduces seemingly unnecessary spending:
      Docs need to know about costs but shouldn’t necessarily be forced to do a cost-benefit analysis for every patient…besides, the CBA really only applies to populations, not individuals.

    • The issue of ordering expensive tests is hard enough.

      And even harder, perhaps, is how to deal with the costs imposed on families when doctors extend the lives of the very old.

      There have been numerous articles, such as Michael Wolff in New York magazine, where the adult children of Alzheimer’s patients are deeply resentful that someone did heart surgery on their parent at age 80.

      Longer life spans can impose huge costs on families, when the patient can no longer care for themselves. We may someday see the day when instead of being paid to do surgery on the old, doctors are taxes for doing so.