The Difficulties That Economic Concepts Pose for Clinical Practice

Suppose that economic efficiency analysis, whether of the CEA, CBA, or other less formalized sort, lays the groundwork for recommendations about the kind and amount of healthcare to use—fewer diagnostic MRIs in certain low-yield situations and very cautious introduction of new, expensive drugs, for example, and more hip replacements and much more assertive and widely diffused prenatal care. The former, service-reducing steps would not constitute the elimination of merely wasteful procedures that generate no net health benefit. They would constitute something much harder: genuine rationing, in which some patients did not get what for them would be optimal care. How does such rationing for efficiency relate to the ethical obligations of healthcare providers? The traditional (at least traditionally professed) ethic of physicians is one of loyalty to individual patients. Generally, in turn, that loyalty is interpreted to mean beneficence: doing whatever benefits a patient the most, within the limits of what the competent patient willingly accepts. If healthcare is to be rationed in order to control the resources it consumes, however, will the basic clinical ethic have to change? This potential clash between traditional ethical obligations and the economic and social demands of the new medicine in an age of scarcity is one of the central foci of ethical controversies in medicine as we enter the twenty-first century.

One can divide the potential views here into incompatibilist and reconciliationist camps: those who think that the demands of societywide (or at least large-group) efficiency cannot be reconciled with the ethical obligations of practitioners, and those who think they can be. The incompatibilists will end up in two different positions: (1) the "well, then, to hell with morality" view in which one is willing to pursue economic efficiency anyhow; and (2) the anti-efficiency stance that opposes rationing in the name of a morality of strict beneficence toward individual patients. Reconciliationist views will also come in distinctly different sorts. (1) Parties more distant from the patient than clinicians should make all rationing decisions, and clinicians should then ration only within pre-determined practice guidelines—the separation-of-roles position. (2) As a provider, one's proper loyalty to a patient, though not dominated by efficiency, is to the patient as a member of a just society; this then enables the clinician to ration with a clean conscience if based on considerations of fairness and justice (Brennan). (3) Patients are larger, autonomous persons; rationing can then be grounded in the consent of the pre-patient subscriber to restrictions on his or her later care (Menzel, 1990). (Why would the patient consent?—to reserve resources for other, more value-producing activities in life.)

The strength of the incompatibilist views may seem to be that they call a spade a spade, but their abiding weakness is that they just dam up the conflict and create later, greater tensions. The reconciliationist views, on the other hand, deal constructively with the conflict and allow conscientious clinical medicine to find roots in a more cost-controlled, socially acceptable aggregate of healthcare. Their weakness may be the great difficulties they face in actual use. The separate-roles view requires extremely clear formulation of detailed care-rationing practice guidelines in abstraction from the medically relevant particulars of individual patients; by contrast, bedside rationing in which clinicians make substantive rationing decisions may be preferable and necessary (Ubel). The patient-in-a-just-society model requires a great degree of agreement on what constitutes a just society. And the prior-consent-of-patients solution requires not only accurate readings of what restrictions people are actually willing to bind themselves to beforehand but also a willingness of subscribers and citizens to think seriously about resource trade-offs beforehand and then abide honestly by the results even when that places them on the short end of rationing's stick.

Undoubtedly this discussion is not about to reach immediate resolution soon in societies that are enamored of ever-expanding healthcare technologies, pride themselves on respecting individual patients, and are determined to steward their resources wisely.

Beat The Battle With The Bottle

Beat The Battle With The Bottle

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