Doctors are being pulled every which way but loose. On one hand, patients want optimal care. On the other, they are told by the Medical Establishment they must cut costs. Some advocate that they become killers of seriously ill or disabled patients who want to die—perhaps even the mentally ill. Others say they should participate in rationing. Their incomes are under stress as increasingly lean capitation compensation hits their wallets. Whatever doctors do, often somebody is going to be upset—often themselves.
This is the environment in which an AMA Ethics Committee opinion tells doctors they have an ethical duty to cut costs. From the AMedNews story:
Chicago Physicians have an obligation to recommend the less expensive option when the available medical alternatives offer a “similar likelihood” of patient benefit, according to ethics policy adopted at the AMA Annual Meeting. Doctors ought to be “prudent stewards of the shared societal resources with which they are entrusted,” says the ethical opinion. The Council on Ethical and Judicial Affairs report overcame objections that it could wrongly limit physicians’ ability to advocate for the interests of individual patients when those conflict with the need to constrain health care costs. Medical spending consumes nearly 18% of the U.S. gross domestic product.
I think the dissenters are correct. The doctor’s first and overriding obligation must be to each individual patient—not to his/her patient load, insurance company, President Obama, or society. True, if doctors go less expensive only when that will almost surely not lead to a less efficacious result, doing so is absolutely appropriate. Alas, I think that’s a big if. While there are many examples when the less expensive choice is perfectly fine, e.g. a generic over a brand name, that line is not always clear. What if, say, Test A has a 10% greater chance of detecting pathology than Test B, but costs $5000 more: Should the doctor be ethically required give test B to save the money? All other things being equal, I think not.
In this sense, the ethics opinion furthers the ongoing great deprofessionalization of medicine because it pushes doctors away from purely patient-centered concerns. I have tremendous sympathy for the lament of one physician:
I started as a physician-healer, then I became a provider, and now I’m a steward.
Yes indeed: We are all technocrats now.