You probably want your doctor to care about people, but how much do you want her to care about all of them? That’s the question I ask when I read articles – generally by bioethicists, often respectable ones – asserting that one of the moral responsibilities of physicians is to be responsible stewards of the healthcare dollar.
This rhetoric concerns me, because I worry it may ultimately degrade the already-challenged physician-patient relationship.
The cornerstone of medicine, the most fundamental principle, in my mind, is the absolute, rock-solid belief that your doctor is your unqualified advocate and will work as hard as possible to provide you with the best medical treatment possible, as if you were a member of her own family (Dr. Marty Samuels and I originally described this as “The Uncle Marvin Test”).
To be clear: this doesn’t mean the most expensive pills – by all means prescribe or substitute an equivalent generic, when available. This doesn’t mean the most expensive diagnostic studies – it’s generally in the patient’s medical interest to avoid unnecessary procedures that usually carry some intrinsic risk and also can lead to false positive results that can in turn lead to needless anxiety — and on occasion, permanent harm. This doesn’t mean extra days in the hospital – a hospital is one of the world’s most dangerous places, and it’s often in a patient’s best interest to be discharged as soon as possible (see here if you need more convincing).
And this doesn’t mean any intervention the patient requests – as Atul Gawande has poignantly described, sometimes helping a patient decide not to pursue a likely futile therapy is the right thing for a doctor to do (although, as I previously wrote in a NYT op-ed, I’ve also seen some doctors abandon hope prematurely).
But it is critical that patients can have confidence that their physicians are offering them the best medical advice, and not to worry that their doctors are trying to somehow balance the costs associated with the care of an individual patient with the broader healthcare needs of the society at large.
In part, my concern stems from an inherent distrust of those who claim to be looking out for “the people,” and who express generic and often patronizing concern for the unnamed masses, as in my experience, this professed concern is often coupled to remarkable contempt for individual people.
I recall with anguish and disgust a coterie of college progressives who would make regular pronouncements about the need for “power to the people,” then would systematically go through the pages of the dormitory facebook, rating and ripping on the students one by one. I shudder to imagine the conversation they might have around the social utility of withholding care from your grandmother (or one of theirs).
Not only am I inherently distrustful of those who claim to be swayed by the interests of “the people,” but on a more practical level, I’m not sure it’s even possible to meaningfully weigh these two factors in a particular instance – an argument made cogently by Milton Weinstein here.
We clearly live in a world of limited resources – though I admit I’ve always been a deep believer in Paul Famer’s view that we should aspire to provide the best medical care to each patient, and not accept a lower standard of care for the poor or, as I increasingly worry about, the elderly.
Perhaps (and it pains me to say this), physicians have something to learn from our colleagues in the law. It could be that we are better served by an adversarial system of some kind, where at least you can trust your doctor, rather than by a system in which physician’s role is to assess not only your disease but your relative value to society.
We’re not there yet, but when I read about the supposed moral imperative to be responsible stewards of the public healthcare dollar – yes, I worry. And so should you.
David Shaywitz is co-founder of the Harvard PASTEUR program, a research initiative at Harvard Medical School. His a strategist at a biopharmaceutical company in South San Francisco. You can follow him at his personal website. This post originally appeared on Forbes.
I cannot imagine how we could say that a physician should be liable for “society’s” costs (which might conflict with his patient’s medical needs) anymore than we would expect the architect, lawyer, or management consultant to be liable for “society’s” architecture, laws, or state of the business sector. If that is what the physician wants to do, he should go work for the public-health department, not private practice.
Then there is the bigger problem: Nobody knows what “society’s” costs (or benefits) really are. While there probably is a social-utility function, we have no good way of discovering it (as determined by Professor Ken Arrow decades ago).
Today, too many people equate “government” with “scoeity”. In a constitutional democracy, that’s not the worst thing since sliced bread, but it’s hardly approximates the reality.
I for one can imagine a payment system in which anyone asking such a question would be laughed at because of how riduculously irrelevant such a question would be.
Would your humorous payment system be limited to physician fees, or would it include payments for treatments you prescribe, such as major surgery, hospitalization, brand name drugs (where no generic exists), etc.?
In the current system, the question, “Should your doctor be thinking about society’s healthcare costs?” really means “Should your doctor be thinking about limiting your access to the health care system so that the entity paying for your care saves money?”
This horse has left the barn. Doctors are called upon to manage populations instead of patients now, and doctors are herded into industrial medicine settings where even the needs of populations are subservient to the needs of the corporation to bring in revenue.
Not that the “leadership” will ever use such doctors, but “the people”, including poor, elderly and generally all those formerly known as middle class, will increasingly be deprived of advocacy in health care, thus the need for “empowered consumers”. It is the dawn of a new age, and it’s not Aquarius.