Critical Decisions

The ins and outs of our medical decisions

Should Her Doctor Consider the Cost of Her Care?

Debating doctor’s duties in an era of unaffordable medical care.

Carol Jefferson's right lung x-ray looked the color of a February storm in Northern Minnesota—a blizzard of white making bone and lung invisible. Her lung was "whited out" because she was experiencing a dangerous combination of tumor and infection. Her lung cancer, a result of thirty years of Virginia Slims, had grown to block her left, main bronchus (the major tube bringing air to her left lung) and this blockage had caused a collection of white blood cells to gather on the other end of the narrowing. 

Jefferson's doctor knew that she would eventually succumb to her cancer. But he was not ready to give up the fight, and Jefferson was more than happy to follow his recommendation for aggressive care. So the pulmonologist inserted a bronchoscope into her left lung, in hopes of better identifying the extent of her cancer and, just as importantly, of determining the nature of her infection. The radiation oncologists began irradiating her tumor, hoping to shrink it enough that the infection would be easier to treat. And the medical oncologists talked with her about the possible benefits of salvage chemotherapy. 

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Jefferson was easily convinced to undergo all these treatments. They were her only chance of surviving more than a few weeks, after all. She felt like she had nothing to lose. Besides, she had already maxed out her health insurance costs for the year, meaning that any additional care would essentially be free. 

Free to her, at least. But costly for society. 

Should Jefferson's doctors consider the financial costs of her care in deciding which treatments and tests to offer her? Or in determining which interventions to recommend to her? 

At first glance the answer to these questions seems obvious. Doctors should offer the best possible therapies to their patients regardless of the financial costs to society. It is not the job of doctors to save money for the healthcare system. That's the job of, well, of the system—maybe insurers, maybe Medicare administrators, but certainly not doctors taking care of individual patients. 

Indeed, patients expect their physicians to work as their advocates, tirelessly promoting their best interests. If this expectation is not met, they're going to have a hard time trusting their physicians. Would you want to go to a doctor who was skimping on your care in order to save someone else's money?

However, I am convinced not only that doctors ought to pay attention to the societal costs of the treatments they recommend to patients, but also that the health and well-being of our society depends in no small part on getting physicians to pay more attention to these issues.

Don't believe me?  I'm not surprised. It's going to take a few more posts for me to lay out a skeleton version of my argument. And it will start, next post, with a simple cough.

Peter Ubel, M.D., author of Critical Decisions and Free Market Madness, is a physician, behavioral scientist, and Professor of Business and Public Policy at Duke University.

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