Expensive care in bad situations an ethical dilemma for physicians

The amount of care to provide to a patient when the chances for survival are limited creates an ethical quandary for physicians. What physicians are required to do for their patients and the impact of that care on cost were discussed Sunday in “I Don’t Care How Much It Costs — I Want It for My Patient!”

Michael Nurok, M.B., Ch.B, Ph.D.

Michael Nurok, M.B., Ch.B, Ph.D.

The first challenge is moral distress, which occurs when a health care professional believes he or she knows the ethically correct action but cannot follow that action because of an interpersonal, institutional, regulatory or legal constraint, said Michael Nurok, M.B., Ch.B, Ph.D., Director of the Cardiac Surgery ICU at Cedars-Sinai Medical Center, Los Angeles.

“We expect there to be a relationship of value,” Dr. Nurok said, but there may be conflict between value sociologically and economically.

That also leads to an uncomfortable conversation about rationing of care, particularly in the ICU. But studies show that rationing in the ICU has not changed outcomes, he said. In addition, ICU costs only account for about 20 percent of total care costs because a hospital stay outside the ICU still must cover the costs for staff and the facility.

“So what do we do with all of this?” Dr. Nurok asked. He then reviewed what might be considered appropriate or inappropriate care and added his own conclusions:

  • Value is a dominant theme in health care
  • Cost is a language through which moral distress is often articulated
  • The cost of delivering an outcome is weighed versus the desirability of that outcome at a given cost
  • We ration care implicitly when hospitals are under strain with a questionable effect
  • Inappropriate care is inappropriate despite a low likelihood of increasing cost.
Nicholas Sadovnikoff, M.D.

Nicholas Sadovnikoff, M.D.

Nicholas Sadovnikoff, M.D., said he looked at the dilemma from a point of view of ethics and moral philosophy. For example, the money spent on caring for a very sick patient in an ICU could be used to fund a free vaccination project for children.

A good guide in this situation, he said, is principlism, which involves autonomy, beneficence, nonmaleficence and distributive justice. An alternative approach is utilitarianism, which judges actions by the consequences they achieve. He also discussed the American Medical Association Code of Ethics and the World Medical Association’s Declaration of Geneva.

Dr. Sadovnikoff, an Associate Professor at Harvard Medical School and Co-Director of the Surgical Intensive Care Unit at Brigham & Women’s Hospital, ended his review of ethics by offering some conclusions:

  • Medical treatments are unequally distributed
  • Implicit (but rarely explicit) rationing occurs
  • There is no good moral argument for physicians to use cost-containment as a rationale for withholding therapies at the bedside
  • The physician thus is essentially compelled to advocate for the patient, irrespective of the expense entailed
  • Limitation decisions based on finances are left to administrators and legislators
  • They have no appetite for being responsible for curtailing individuals’ access to treatments
  • The percentage of the GDP spent on health care in the U.S. continues to balloon disproportionately compared to other Westernized systems.

“Physicians need to be involved in policy-making to redirect us from the collision course we are on,” Dr. Sadovnikoff said.

Neal H. Cohen, M.D., M.P.H., M.S.

Neal H. Cohen, M.D., M.P.H., M.S.

Neal H. Cohen, M.D., M.P.H., M.S., Professor and Vice Dean of the University of California, San Francisco, School of Medicine, offered another perspective — the physician’s responsibility to the health care system.

The physician remains the best advocate for the patient with respect to clinical decision-making and must consider the goals of care, clinical capabilities and whether they are aligned.

Variables in this discussion are the best interest of the patient, which may or may not be in the best interest of the other parties, including the hospital or health system, the providers and the payers.

“While the physician serves as patient advocate, interests of all parties should be considered,” Dr. Cohen said. “When making management decisions, all clinically appropriate alternatives should be considered and the physician should balance the benefits, risks and costs associated with each alternative in determining what is in the patient’s best interest. These discussions should not be limited to end-of-life decision-making.”

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