Thursday, July 12, 2012

Physicians, Ethics and Costs


Physicians, Ethics and Costs

A thoughtful article in this week’s New England Journal ofMedicine entitled “Centsand Sensitivity — Teaching Physicians to Think about Costs” by Lisa Rosenbaum, M.D., and Daniela Lamas, M.D. is an interesting perspective on the culture of medicine which rewards and emphasizes, completeness of evaluation weighed against the societal need to lower costs.  They ask the important question,

“Is there a place for principles of cost-effectiveness in medical education? Or does introducing cost into our discussions threaten to destroy what remains of the patient–physician relationship?”

Their answer is that cost should play a role however the examples they give make it clear that the costs to the individual are the important factor and not necessarily the societal costs.  They quote Dr. Martin Samuels of Boston’s Brigham and Women’s Hospital as stating:  “when physicians start weighing society’s needs as well as those of individual patients, they begin to lose the essence of what it means to be a doctor. When we lose our personal responsibility to individual patients, he says, ‘We are in deep trouble.’”

It is important to understand just what is being discussed and in many ways, I strongly agree with the statement by Arthur Caplan that they site, “The fight about cost is a smokescreen,” says Caplan. “What’s really at issue is the definition of ethical physician advocacy.” 

Health professionals who care about patients need to care about the person and not only the patient.  Caring about a person means understanding them as an individual and not only as an organism with a disease.  A person’s economic health is a part of their personhood just as is their psychological health, their family connections, their spiritual health and their work.  Cost is an important factor to many people but it is not necessarily more important than the other pieces that make each of us unique. 

The article does understand that the cost to the individual is the important consideration finishing with the statement,

“Now some educational reformers are offering us an added ethical incentive.  Put simply, helping a patient become well enough to climb the stairs to his apartment is meaningless if our care leaves him unable to afford that apartment. Protecting our patients from financial ruin is fundamental to doing no harm.”

Just to emphasize the point.  A health professional caring for a person should always think about the costs to that individual, financial and otherwise and should never think about the cost to society when it conflicts with the good of the individual.  That is the true essence of being a care giver and is the true essence of being a Health Assistant.  Of course the irony of that ethical imperative is when you act in that manner, focusing on the needs of the individual, the result is that the costs to society as a whole are decreased significantly.  That is also the strong lesson that we at Accolade have learned.