post by Paul Kelleher
Aaron Carroll writes about the ethics guidelines (pdf) recently released by the American College of Physicans:
But the part that raised my eyebrows the most, and where I’m not sure I am in total agreement has to do with a 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.
I’m sure many of you are shocked by my concern with this statement. Let me explain.
I talk a lot about the fact that we, as a society, need to think about cost-effectiveness if we are going to get a handle on the cost of health care. This means saying no to some treatments and tests, because we have to use health care resources responsibly. When I say such things, inevitably someone counters me by questioning whether I would feel the same way if my child’s life was on the line.
The answer is, of course not. If my child’s life were at stake, I would fight tooth and nail to get anything – and I mean anything – to save him or her. I’d do it even it it cost a fortune and might not work. That’s why I don’t think you should leave these kind of decisions up to the individual. [...]
Similarly, I don’t think that it’s necessarily fair to make it a physician’s responsibility. I also want my child’s doctor to fight tooth and nail to get anything that might save my child...Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.
So whose job is it? Well, mine for instance. That’s what I do as a health services researcher. That’s what policy makers should also do. That’s what we, as society should do. There are people who should have the responsibility of debating and deciding what is and is not cost-effective. They should have to make decisions that may be unpopular, and they should have to face the wrath of those whom the decisions impact.
On my reading of the ethics guidelines, the American College of Physicans is largely in agreement with Carroll. Consider again the passage he quotes:
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.
The College defines parsimonious care not as care that "maximizes QALYs per dollar spent" or care that "maximizes net monetized benefits", but as "care that utilizes the most efficient means to effectively diagnose a condition and treat a patient." Here the stipulated goal is effective diagnosis and treatment, and physicians are instructed to use the most efficient means available to achieve it. Dr. Virginia Hood, the president of the College, elaborates:
"Parsimonious is a good word in the sense that it means that you use only what's necessary," she said.
So I don't see the College recommending that physicians should withhold effective therapies from their patients based on cost. But then there is also this in the College's guidelines:
In making recommendations to patients, designing practice guidelines and formularies, and making decisions on medical benefits review boards, physicians’ considered judgments should reflect the best available evidence in the biomedical literature, including data on the cost-effectiveness of different clinical approaches.
Unfortunately, the College does not make it clear exactly how cost-effectiveness data is to be used by physicians. Later in a section entitled "The Physician and Society," and in a sub-section entitled "Resource Allocation," the College writes that "decisions about resource allocations challenge the physician’s primary role as patient advocate." Still, the document is quite clear where the physician's loyalties should be. Indeed, the document echoes Carroll's remarks about his preferred division of labor:
1. As a physician performs his or her primary role as a patient’s trusted advocate, he or she has a responsibility to use all health-related resources in a technically appropriate and efficient manner. He or she should plan work-ups carefully and avoid unnecessary testing, medications, surgery, and consultations.
2. Resource allocation decisions are most appropriately made at the policy level rather than entirely in the context of an individual patient–physician encounter. Ethical allocation policy is best achieved when all affected parties discuss what resources exist, to what extent they are limited, what costs attach to various benefits, and how to equitably balance all these factors. Physicians, patient advocates, insurers, and payers should participate together in decisions at the policy level; should emphasize the value of health to society; should promote justice in the health care system; and should base allocations on medical need, efficacy, cost-effectiveness, and proper distribution of benefits and burdens in society.
I tend to agree with Carroll's take on whether doctors should ration at the bedside. And I think the American College of Physicians does too.
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