Ethics in forefront of move to control medical costs
Physicians have obligation to all patients
EXECUTIVE SUMMARY
The need to reduce, avoid, or not to adopt costly treatments which provide very small benefits, and the need to provide everyone with treatments that are very effective and reasonably priced, present ethical challenges. Bioethicists argue that:
- Physicians need to take into account other patients, other people, public health, and the health care system.
- Patients are becoming more aware of risks of unnecessary treatments.
- Indirect harms of unnecessary treatments include lack of access to care.
From an ethical point of view, few would argue against the need to reduce harmful treatments or treatments that don’t provide any benefits, since providers have a duty not to harm and a duty not to be wasteful. "The harder ethical case is the need to reduce, avoid, or not to adopt those treatments that are very costly but provide only very small benefits," says James Dwyer, PhD, associate professor of bioethics and humanities at State University of New York (SUNY) Upstate Medical University in Syracuse.
Dwyer says there is a need to develop fair and reasonable ways to address this category of cases, and a need to provide everyone with treatments that are very effective and reasonably priced. "In the United States, we have really failed at this," he says. "There are many reasons for the interest in controlling the costs of medical care. There may be some bad reasons, but there are plenty of good reasons."
Dwyer challenges the idea that the physician’s duty is always and only to one particular patient. "This idea is modeled on the advocacy that lawyers provide to a client in a criminal case. Whether or not that is the right model for criminal justice, it just doesn’t fit medicine," he says. "Physicians always have more than one patient, and more than one concern."
Although the individual patient may be their primary concern, physicians need to take into account other patients, other people, public health, and the health care system, argues Dwyer. "Sometimes they need to advocate for their patients, but they also have a duty of stewardship and fairness. We need to develop practices and systems that also help them to fulfill those duties," he says.
As health care resources get progressively more constrained, there will be a call by governmental and private health care plans to reduce unnecessary or wasteful care, says Michael Weber, MD, professor of medicine at SUNY Downstate College of Medicine in Brooklyn, NY. "While on the surface, these calls for restraint would appear very reasonable, they can create the specter of rationing," he adds. "Of course, this has already been happening for many years."
The denial by payers of requests for newer drugs or for diagnostic or surgical procedures, although quite often justified on legitimate medical grounds, can create the impression that financial considerations outrank optimal patient care. In some settings, the use of practice guidelines, which by necessity are often based on selective interpretations of evidence, can be used or misused to restrict access to more costly care. "These actions can create an ethical dilemma in which cost-saving measures are enforced under the guise of best practices,’" says Weber.
Perhaps most troubling of all from an ethical viewpoint, says Weber, are schemes whereby health plans provide personal financial rewards to those medical practitioners who demonstrate skill at minimizing costs, and impose pressure on practitioners if they appear to be over-utilizing diagnostic or therapeutic resources. "Bluntly put, these financial strategies can have the appearance of putting clinicians into adversarial relationships with their own patients — surely a troubling conflict of interest for medical professionals," he says.
It cannot be denied that there is a meaningful degree of waste and abuse in the utilization of health care resources, and it is entirely necessary that these unacceptable practices be reined in, acknowledges Weber. "The best approach is an open and transparent public discussion on how this can be most fairly and honestly achieved, without resorting to heavy-handed and questionable cost-saving strategies," he says.
Growing awareness
Much of the movement toward parsimonious medicine will be internally driven by practicing clinicians and patients, rather than externally driven by regulatory requirements, predicts J.S. Blumenthal-Barby, PhD, MA, assistant professor of medicine and medical ethics at Baylor College of Medicine in Houston, TX.
"We see this in the Choosing Wisely campaign, where professional medical societies are working come up with lists of unnecessary, wasteful medical tests and procedures," she says. "And patients are becoming more aware of and comfortable with the idea that sometimes less is more."
Patients and physicians are getting on board with parsimonious medicine less because of reasons of social justice, or saving resources for others, and more for reasons of personal and professional well-being, according to Blumenthal-Barby. "I think that these movements are good, because they shift the focus from arguments about the greater good and rationing’ — which are inherently controversial, and as such fail to get practical traction — to arguments about individual well-being and professional obligations," she says.
Dwyer points to international comparisons indicating the United States spends far more than any other country on health care. "Yet by any measure of health, we don’t fare very well," he says. "What also stands out in my mind are small area variations — the differences in costs and outcomes across different areas within the United States."
Indirect harms of higher-cost health care are substantial, adds Dwyer, such as pricing many people out of care, and making universal health care harder to achieve. "We need to remember that the point is not to spend more money on health care, or even to develop new technologies," he says. "The point is to provide good care, and to achieve relatively healthy and long lives, at reasonable costs."
Dwyer says his chief concern is that the entire discussion about cost-effective care will be framed unfairly. "We will examine — as we should — small ethical problems that will arise in attempts to control costs," he explains. "But we will ignore huge ethical problems that exist in the current system, that arise from not including people and from using a fee-for-service payment system."
A related concern is that there will be too much focus on individual physicians or individual hospitals, while the role of social incentives, systems, and structures will be overlooked. "It will take more and better civic engagement to make deeper changes in the system," says Dwyer. "Health care debates seem to bring out extreme forms of ideology. The evidence, problems, and suffering of people tend to get ignored."
SOURCES
- J.S. Blumenthal-Barby, PhD, MA, Assistant Professor of Medicine and Medical Ethics, Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX. Phone: (713) 798-3785. E-mail: [email protected].
- James Dwyer, PhD, Associate Professor of Bioethics and Humanities, State University of New York Upstate Medical University, Syracuse. Phone: (315) 464-8455. E-mail: [email protected].
- Michael Weber, MD, professor of medicine at SUNY Downstate College of Medicine in Brooklyn, NY. Phone: (714) 815-7430. E-mail: [email protected].
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