One of the most important differences between my book, Priceless: Curing the Healthcare Crisis, and the conventional literature on health policy is my belief that patients should be encouraged to choose between healthcare and other uses of money. And that’s not just for small expenses. I think patients should be encouraged to make choices involving expensive procedures as well. If I’m right, doctors will have to take a new approach to medicine, and in taking this approach, they may have to rethink how they view medical ethics.
The latest edition of the American College of Physicians manual on ethics created quite a stir with the following passage:
Physicians have a responsibility to practice effective and efficient healthcare and to use healthcare 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.
On the right, American Enterprise Institute scholar Scott Gottlieb reacts by writing, “Parsimonious, to me, implies an element of stinginess, and stinginess implies an element of subterfuge.” On the left, Aaron Carroll, a professor of pediatrics at Indiana School of Medicine, writes:
I would fight tooth and nail to get anything—and I mean anything—to save [my own child]. I’d do it even if it cost a fortune and might not work. That’s why I don’t think you should leave these kinds of decisions up to the individual. Every single person feels the way I do about every single person they love, and no one will ever be able to say no. That’s human.
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. Many times, physicians have long-standing relationships with patients. 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 a roundabout way of saying that only the government can ration care the right way.
My view: people in healthcare have become so completely immersed in the idea of third-party payment that they have completely lost sight of the whole idea of agency. Can you imagine a lawyer discussing the prospects of launching a lawsuit without bringing up the matter of cost? What about an architect submitting plans for a building but completely ignoring what it would cost to build it? Outside of medicine, can you imagine any professional anywhere discussing any project with a client and pretending that money doesn’t matter? Of course not.
Then what is so special about medicine? Answer: the field has been completely corrupted by the idea that (a) patients should never be in a position to choose between health benefits and monetary cost, (b) doctors shouldn’t have to think about such tradeoffs either, (c) to insulate the patient from having to choose between healthcare and other uses of money, third-party payers should pay all the medical bills, and (d) since no one else is going to think about what anything costs, the third-party payer is the only entity left to decide which services are worthwhile and which ones aren’t.
1. Lois Snyder, editor, “American College of Physicians Ethics Manual, Sixth Edition,” Annals of Internal Medicine (2012): 73–104.
2. Rob Stein, “Physicians Group: Weigh Costs in Treating Patients,” National Public Radio, All Things Considered, January 2, 2012. http://www.npr.org/2012/01/02/144591018/physicians-group-weigh-costs-in-treating-patients.
3. Aaron Caroll, “Is it unethical for physicians not to consider costs?” The Incidental Economist (blog), January 4, 2012, http://theincidentaleconomist.com/wordpress/is-it-unethical-for-physicians-not-to-consider-costs/.