post by Bill Gardner
A now famous passage in the American College of Physicians (ACP) Ethics Manual states:
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.
- Model 1: A doctor is responsible for, and will care for, her patient, where a patient is someone whom you have seen, whom you have agreed to care for, and who has consented to your care.
- Model 2: A doctor -- or more often a practice -- is responsible for a defined group of people. The doctor is supposed to care for them, whether she has met them or not.
Under model 1, you are expected to do all you can for your patient. But the doctor can only give you care until she's out of time or until you or your insurer run out of money. Then she can say, to each patient, "I've done all I can for you." And she can say this with complete sincerity. But bienvenidos a realidad: there isn't enough time or money to take care of every medical need. So model 1 works only if there are some people who cannot access care, and who despite their needs do not become patients. In model 1, some people with arthritis get artificial hips, and others get nothing.
Under model 2, the limits on time and resources hit in a different way. The doctor cannot turn patients away. But bienvenidos a realidad: there isn't enough time or money to take care of every need. So she has to deliver care efficiently, that is, parsimoniously. In model 2, a few people with arthritis get new hips, the rest get canes, and no one goes without care. These means, however, the doctor can't say to each patient, "I've done all I can for you."
Both models are ethical views of medicine; and under both models, doctors give all the care they can. But they are different ethics. Under model 1, the doctor does not stint care for any patient, but some persons in need are Not Her Problem. Under model 2, Her Problems include everyone in need, but some of them get less care than the doctor or patient might want.