The ACP Advocate Blog
by Bob Doherty
Tuesday, September 29, 2009
Is it morally objectionable for physicians to consider cost in treatment decisions?
Yes, according to a majority of physicians in a recent poll. The survey, which was reported in the September 14 edition of the New England Journal of Medicine, found that 54% of surveyed physicians said that they had "moderate" (40%) to "strong" (14%) moral objections to using cost-effectiveness data to determine which treatments to offer to patients. 45% said they had no such moral objections.
A third of physicians had moderate to strong disagreement with limiting reimbursement for high cost procedures or drugs in order to help expand access to basic coverage to those who do not have it, while 67% favored such limitations to expand access for others. Primary care physicians were more likely than surgeons or procedural specialists to support limits on payments to help fund basic care for others.
The survey has some other surprising findings. While a large majority of physicians agreed that physicians are ethically obligated to care for the uninsured and underinsured, 27% moderately or strongly disagreed. Slightly more than one out of five physicians agreed that addressing societal health policy issues, as important as that might be, falls outside their professional obligations as physicians.
Like any poll, how a question is worded can produce a quite different result. I wonder, for instance, if fewer physicians would have moral objections to cost-effectiveness data if it was to "guide" or "inform" patient care decisions rather than "determine which treatments will be offered to patients" as stated in the survey. I can see why the notion that a treatment might not be even offered to patients, if it was determined not to be cost-effective, would raise moral objections. Comparative effectiveness research, at least the way ACP has envisioned it, should be used to engage patients in shared decision-making with their physicians on which course of treatment might work best for them, not to deny them this choice by taking the more expensive treatments off the table.
At the same time, the survey suggest to me that many physicians do not agree with concepts of social justice and fair allocation of resources as described the Physician's Charter on Professionalism, which has been endorsed by the ACP, the American Medical Association, the American Board of Internal Medicine, among others. The Charter's principle of social justice states that "The medical profession must promote justice in the health care system, including the fair distribution of health care resources." It also states that physicians must have a commitment to a just distribution of finite resources:
"While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care. The physician's professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one's patients to avoidable harm and expense but also diminishes the resources available for others."
Today's questions: Do you personally have a moral objection to using cost-effectiveness data to determine the treatments offered to patients? What about to guide and inform such treatments? Do you agree or disagree with the Charter's view that physicians must be committed to social justice and a fair distribution of finite resources?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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