With finite healthcare resources, do physicians have a duty to serve society broadly by being responsible stewards of those shared resources, or is their obligation to the patients before them incompatible with any rationing? The balance of duties to patients and to society was the subject of a debate at ASCO 2014.
Beverly Moy, MD, MPH, Clinical Director of the Breast Oncology Program at Massachusetts General Hospital, Boston, set the stage by noting that therapy for cancer amounts to approximately 5% to 11% of the total healthcare budget and is the most rapidly growing segment of healthcare. The costs of targeted therapy range from $500 to >$30,000 monthly or per cycle. These ballooning costs present an ethical dilemma. The professional norm that says that the first and foremost responsibility of oncologists is to do what is best for their patients is eroding in the face of the ever-increasing growth of healthcare costs, said Dr Moy. “Oncology providers are faced with balancing their duties to individual patients and society.”
Reshma Jagsi, MD, DPhil, Department of Radiation Oncology, University of Michigan, Ann Arbor, argued that physicians’ moral duty to their patients is paramount in any clinical encounter, but in their privileged professional role, they “have an obligation to serve society more broadly.” Healthcare spending can crowd out other spending that is essential to promote health, she said. The question is not whether to ration resources, but how to ration them.
“Physicians owe it to society to help ensure that resources are allocated in a way that is congruent with broader moral intuitions, as well as to reduce waste to maximize the value of our interventions,” said Dr Jagsi. “Physician stewardship of society’s scarce resources is best accomplished at the societal level rather than the individual level.” Physicians must call attention to general areas of waste and develop solutions to improve efficiency, as well as “lead the development of a robust evidence base for the assessment of value, including studies to identify situations of overdiagnosis and overtreatment in healthcare,” she added.
Recent studies on the financial burden of cancer care highlight how prescribing costly care can hurt the individual patient. When strong evidence suggests that clinical benefit is not compromised by a more efficient approach to treatment, physicians have a duty to consider cost, Dr Jagsi advised.
The “Choosing Wisely” campaign has engaged professional organizations in identifying practices that may represent the inappropriate use of finite societal resources. To this end, ASCO has issued “Top 5” lists of opportunities to improve the quality and value of cancer care, she noted.
The professional ethic of medicine is patient-centered, countered Daniel P. Sulmasy, MD, PhD, Associate Director of the MacLean Center for Clinical Medical Ethics, University of Chicago, in which the goal of the clinical encounter is to promote the good of the individual patient. Patients must trust that physicians will do the best for them in light of the available resources. “Questions of justice might arise regarding the unequal distribution of medical resources across the globe, but such questions are not answered in the immediacy of the bedside encounter, with the individual patient in a particular society,” he said.
Economists suggest that medicine is a public good, Dr Sulmasy said, given the necessity of health for access to many other goods. “The existential situation of sickness demands that patients be able to trust that their doctors are applying this public good for their individual benefit, not the physician’s personal benefit or the good of society at large,” said Dr Sulmasy.
Bedside rationing of care undermines trust, “disrupts the balance between profession, market, and state, and is likely to be idiosyncratic and unjust to individual patients,” he suggested.