Balancing Patient Care and Public Health
Do ‘the needs of the many’ ever outweigh ‘the needs of the few’?
http://www.medpagetoday.com/PublicHealthPolicy/Ethics/52225?xid=nl_mpt_DHE_2015-06-20&eun=g578717d0r
Physicians are increasingly being asked to balance the interests of their individual patients with those of the public at large — for example, when they are considering prescriptions for antibiotics or for ultra-expensive cancer therapies for patients who might benefit from them but also might not. In the first case, the public danger is promotion of drug-resistant organisms; in the second, it’s the increased cost that ultimately everyone bears through insurance and Medicare taxes.
We contacted a variety of healthcare professionals via e-mail to ask:
Can physicians ethically withhold treatments from patients when benefit is not guaranteed but there is a definite adverse impact on the public at large?
How should physicians strike the correct balance?
The participants this week are:
James E. Bailey, MD, MPH, FACP, professor, medicine and preventive medicine and director, Center for Health System Improvement at the University of Tennessee Health Science Center in Memphis
Marc I. Leavey, MD, primary care specialist at Lutherville Personal Physicians, a Mercy Medical Center Community Physician Site in Lutherville, Md.
Thomas L. Horowitz, DO, a physician in private practice in Los Angeles
Peter J. Rice, PharmD, PhD, BCPS, FAPhA, professor, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora
Zubin Damania, MD, founder and CEO, TurnTable Health, a direct-pay primary care clinic in Las Vegas
A Question of Ethics
James Bailey, MD: “All healthcare workers are ethically bound to work for the benefit of their patients to the best of their ability, and ‘at least do no harm.’ These mandates require us to only offer treatments that on balance offer more benefit than harm to the individual patient. Balancing benefits and harms is often difficult in cases like chemotherapy for terminal cancer where potential benefits are small and harms can be great. But where harms clearly outweigh benefits, physicians are obligated to protect their patients from these dangerous treatments. In my experience, most treatments that have an adverse impact on the public at large present more harm than benefit to the individual patient as well.”
Marc Leavey, MD: “Putting the physician in the role of actively and singularly withholding treatment is to place that physician in an impossible situation. One’s personal ethics, and the mores and beliefs of the patient and population involved all play roles. Today, the patient is often an active participant in healthcare decisions, and may take a personal or altruistic posture. The physician treating that patient has a moral and ethical duty to the patient at hand, to do the best that can be done, to not harm the patient, to be true to his or her training. While balancing the needs of the one patient in front of the physician with the amorphous future, with yet undiscovered solutions that may impact it in the future, one needs to avoid getting trapped in the popular line from Star Trek, ‘The needs of the many outweigh the needs of the few.'”
Thomas Horowitz, DO: “Part of a physician’s obligation is the public health responsibility. Reporting is the cornerstone. However, antibiotic stewardship and immunization compliance has become a big issue. Our obligation is to explain to the patient the ‘why’s. But we should do the right thing.”
Evolving Attitudes
Peter Rice, PharmD: “Making decisions in the best interest of individual patients is the foundation of our medical system. In my experience, physicians are strongly committed to their patients, whose care holds the highest priority in the decision making process. That being said, both physicians and patient attitudes are evolving over such topics as antibiotics; physicians and pharmacists are educating, and patients are beginning to understand that it is in the best interests of all to reserve antibiotics for patients who require them and can benefit from them. It is appropriate for all healthcare professionals to remain advocates for their patients while maintaining good stewardship so that treatments are used effectively, are equitably available, and remain effective for future patients.”
Zubin Damania, MD: “In the old days of Health 1.0 (most of the 20th century), doctors treated the patient at hand in a very autonomous way, and systemic considerations seemed a fairly low priority. Currently in Health 2.0, these wider issues roar back with a vengeance and doctors are asked constantly to think of the public and systemic impacts of decisions. Of course, the reality is that many are just trying to survive the increasing workloads and administrative burdens and don’t really have the time to elicit the deeper patient motivations, or educate patients on the lack of utility or potential personal or systemic downsides of treatments or testing. Ethically, I think we have a responsibility to consider these aspects, but our current system doesn’t support the process.”
Leavey: “The question of withholding treatment when there is a poor likelihood of successful outcome has been a part of medicine for ages. In history, with many treatments of limited efficacy, there was often less weight to the decision. The patient may pass the crisis and survive, but the physician’s role was primarily passive or supportive. With the advent of more accurate diagnoses and effective treatments, that role becomes much more significant. The concept of triage, originating on the battlefield but now a part of everyday hospital emergency care, is predicated on being able to tell who is the “sickest,” and who may be so gravely injured or ill that palliation and comfort care are all that can be offered.”
Finding the Correct Balance
Bailey: “Physicians can best strike the correct balance by practicing true evidence-based medicine and adequately considering potential harms as well as benefits to individual patients. Often I find that potential harms are inadequately considered. Doctors only like to think about the potential benefits of the therapies they offer. But we are obligated to offer all therapies where benefits clearly outweigh harms that a patient might reasonably access or which their insurance covers. As patient advocates, physicians should inform policymakers and the public about high-value healthcare where benefits clearly outweigh harms. This is the kind of care we need to work to make affordable for everyone.”
Horowitz: “Medical ethics require us to inform patients of the pro’s and con’s of treatments we believe will comfort or cure them. We should not offer treatments that are ineffective. It there is something that the general medical community believes is useful, but the provider does not believe in, then we are obligated to offer a discussion with another provider that may be able to give a second opinion. Ethics is community standard; when in doubt each facility has a bioethics committee that can help with these dilemmas.”
Rice: “Education plays an important role in balancing the appropriate use of medications. Patients may feel shortchanged if they leave a physician visit without a prescription, and the challenge is to let patients know that they are cared for even though no treatment is needed at the present time. For critical care and terminal patients, healthcare professionals can help patients and families understand and make very difficult decisions to pursue therapies that may not be effective while trying to optimize quality of life.”
Damania: “In Health 2.0, often we are asked to be arbiters of algorithmic medicine and this ignores the unique patient and story before us. It’s often in this story that we can find the correct decision. A vision of Health 3.0 provides the time and autonomy for physicians to truly practice an interpretive, shared decision-making model with patients — to get the story and understand the motivations of the patient, and then render advice that is based on an understanding of both the patient and the larger context into which they fit. This takes time, training, and a culture shift in which these sorts of relationship-based activities are valued as cost-saving, health-promoting, and ethical.”
Leavey: “The relationship between physician and patient is unique. Through the years I have seen patients require enormous services, from transplantation to brain surgery, without any guarantee of success. Their treatments have consumed resources that were of significant financial impact, and that would consume limited time, personnel, or supplies. They were individuals who looked at me with eyes that showed pain, concern, questioning, and trust. To abrogate that trust to an impact of unknown or indirect dimension would seem to go against the obligation of a physician to his or her patient. Shakespeare said it, “This above all: to thine own self be true.” Try not to act hastily, try not to yield to external pressure or arguments, keep an open mind to all aspects of the situation. Primum non nocere.”
Filed under: General Problems
60 minutes recently reported that oncology physicians receive kick backs from Pharma manufacturers when they prescribe certain very high priced chemo drugs. Check it out. So much for ethics and patient care! These new chemo drugs are pushing patients into bankruptcy as the co pays can run to many thousands every month.
See the chapter “The Drug Pushers” in my recently released novel, The End of Healing (www.endofhealing.com) for more of the story on kickbacks from Pharma manufacturers to prescribers. Patients and providers need to stand up against this kind of corruption, profit-seeking, and greed in healthcare at the expense of our most vulnerable citizens.
Inherent in the assumptions underlying Damania’s “Health 2.0” paradigm, is the assumption that paradigms actually exist…and moreover, that they evolve. IF this is true, THEN one applies situation ethics, and seeks the greater good for the average mass of people.
The problem with Situation Ethics, is that it arises in the context of War.
During War, the opportunity to do good, is foreclosed by the fighting itself. In War, good people must choose The Least Bad response to every challenge.
Civil juries have extreme difficulty seeing the relevance of the Law of War, in a peacetime situation, where somebody’s grandmother ate dog food to save money to pay for a surgical procedure that made her worse instead of better. The physician who blathers on about ethical principles that are not shared by the common people, or worse, run contrary to what the common people consider ethical, will get himself into a world of hurt in a courthouse, by merely opening his mouth.
A Constructive Republican Alternative Proposal (CRAP), put forth and implemented by Texas governor Rick Perry, was to limit all medical malpractice claims, to those claims in which the community Standard Of Care was not upheld.
The result has been, that when there’s any doubt, medical ethics must yield to whatever forms of malpractice are in common use. There’s safety in numbers, practicing bad medicine in Rick Perry’s Texas. There’s danger for doctors who perform better-than-standard care, of getting singled out for reprimand if things go wrong. Thus, there’s a dumbing-down effect, that threatens to make every individual’s collective experience with healthcare, less safe and more costly, by creating the appearance that every individual’s healthcare is the same. Care that’s equally bad, and standard, needs not improve, if that’s to be how it is judged.
If anybody took a philosophy class and learned formally about logic, on reading this post, they may notice some examples of fallacious reasoning…to wit..fallacies of composition and of division.
If you noticed that, congratulations. You’re learning.
The starting point, is recognizing that peacetime medical practice is not war, and that situation ethics apply to it rarely, if ever. Doing harm to individuals, for the alleged good of the collective, merely makes the collective, collectively guilty of harming somebody for their personal gain.
In closing, it is noteworthy that this fallacious misuse of situation ethics, has fooled a great many people in the past…and provides a social incentive to ignore facts that contradict the conclusion, that inflicting the harm was justified. What began in the 1930’s as an attempt to prevent a recurrence of the 1918 Influenza epidemic, by a process of creeping application of fallacious reasoning, metastasized into official racism, thence into compulsory sterilization, thence into mass murder…all on the belief of a few German doctors, that Jews were carriers of deadly influenza.
Because Germany’s Jews had no forum in which to answer or dispute the irrational beliefs about their alleged role in the Influenza pandemic, collectively the German government acted unilaterally and largely in secret, harming every individual of Jewish ancestry, whom they could find.
Given the millions of innocent bystanders murdered, so that Hitler’s armies could enter neighboring nations and kill millions of Jews, it should give us pause and sober reflection, when someone advocates that a physician look after the collective interests of someone not a patient, and put those alleged interests ahead of the life of the patient.