This is a follow-up to my post earlier today. Consider two vignettes:
- A patient requests a treatment or diagnostic test from a physician. The physician reasonably believes that the service is of no medical benefit to the patient (perhaps based evidence so strong the vast majority of physicians would concur). At first the physician is reluctant to perform the service, but the patient so desperately wants the treatment/diagnostic test — even paying full price out-of-pocket for it — that the physician yields and delivers it anyway.
- A physician offers a treatment or test to a patient that is widely known to be of no medical benefit. (Perhaps this physician doesn’t know, but let’s presume it is not controversial that it is not beneficial.) All things being equal, the patient would rather not undergo the treatment or test, but the doctor is insistent that it is necessary. The patient yields and the service is delivered. (If it matters to you, and to make this case parallel to vignette 1, let’s suppose the patient is paying full price out-of-pocket.)
In both vignettes a transaction occurred that one party was somewhat reluctant to participate in and the other party wanted very badly. In both cases the treatment is assumed to be medically nonbeneficial. In both cases the patient pays out-of-pocket; no insurance is involved. The difference is that in vignette 1, the physician yielded to the patient’s values and in vignette 2, the patient yielded to the physician. Yet the outcome is the same.
Questions: Do we feel differently about these two cases? Is delivery of the service moral in one case and not another? Would it have been OK for the physician in vignette 1 to refuse provision of (nonbeneficial) care? Would it have been sensible for the patient in vignette 2 to decline it? Would your answer change if the possibility of obtaining second opinions in either case was removed (e.g., an emergency situation or one with limitations on access to alternative care)? Are these vignettes morally symmetric or not?
Which vignette is “patient-centered” care? Which is “consumer-directed”? Which is (or potentially is) “rationing”? What if some IPAB-like board had declared the treatment as nonbeneficial?* What if the doctor had some “skin in the game” (e.g. operating under an ACO or some capitated arrangement)? What if the patient did not have “skin in the game” (fully insured)?
It’s not hard to draw a line from policy we debate to vignettes like these. Is our reaction to such vignettes consistent with our policy preferences?
* Note that the IPAB cannot do this under current law.