Why the Ethics of Parsimonious Medicine Is Not the Ethics of Rationing

By Jon C. Tilburt and Christine Cassel
JAMA. 2013;309(8):773-774. doi:10.1001/jama.2013.368.

The ethics of rationing health care resources has been debated for decades. Opponents of rationing are concerned that societal interests will supplant respect for individual patient choice and professional judgment. Advocates argue that injustices in the current system necessitate that physicians use resources prudently on behalf of society, even in their daily work with individual patients. The debate is important, potentially divisive, and unavoidable.

Various groups have championed the cause of medicine practiced leanly, consistent with the professional responsibility to use resources wisely. These initiatives, which champion “parsimonious medicine,” have highlighted the 20% of routine practices in US medicine that add no demonstrable value to health care but that persist in the inertia and rituals of clinical work. The specialty societies and the Choosing Wisely collaborative outline commonsense principles for avoiding unnecessary, wasteful care.

Recent calls for waste avoidance and parsimonious care are not just a clever way to help physicians ration health care.  Despite the intuitive similarity between themes in rationing and waste avoidance, the ethical rationales underlying the two differ considerably.

The entire article is here.

Study of U.S. Health Care System Finds Both Waste and Opportunity to Improve

By Annie Lowrey
The New York Times
Originally published on September 11, 2012

The American medical system squanders 30 cents of every dollar spent on health care, according to new calculations by the respected Institute of Medicine. But in all that waste and misuse, policy experts and economists see a significant opportunity — a way to curb runaway health spending, to improve medical outcomes and even to put the economy on sounder footing.

“Everybody from Paul Krugman to Paul Ryan agrees it is essential to restrain costs,” said Dr. Mark D. Smith, the president of the California HealthCare Foundation and the chairman of the committee that wrote the report, referring to the liberal economist and Op-Ed columnist for The New York Times, and the conservative Wisconsin congressman who is Mitt Romney’s vice-presidential running mate. “The health care industry agrees, too.”

The Institute of Medicine report — its research led by 18 best-of-class clinicians, policy experts and business leaders — details how the American medical system wastes an estimated $750 billion a year while failing to deliver reliable, top-notch care. That is roughly equivalent to the annual cost of health coverage for 150 million workers, or the budget of the Defense Department, or the 2008 bank bailout.

The entire story is here.

Medical waste: America loses billions to sloppy health care

Pittsburgh Post Gazette
Originally published September 10, 2012

The influential Institute of Medicine has completed a comprehensive review of the nation's health care system, and here's the frightening diagnosis: Nearly $750 billion a year is wasted on unnecessary care, excessive administrative costs, fraud, duplication and poor communication.

The institute's conclusions may not be surprising to anyone who has had to reschedule an appointment because tests results were not available or to repeat a procedure in order to get accurate data. In fact, the group's study found that 20 percent of patients experienced the former and 25 percent the latter.

The entire story is here.

Overtreatment Is Taking a Harmful Toll

By Tara Parker-Pope
The New York Times - The Well Column
Originally published August 27, 2012

When it comes to medical care, many patients and doctors believe more is better.

But an epidemic of overtreatment — too many scans, too many blood tests, too many procedures — is costing the nation’s health care system at least $210 billion a year, according to the Institute of Medicine, and taking a human toll in pain, emotional suffering, severe complications and even death.

“What people are not realizing is that sometimes the test poses harm,” said Shannon Brownlee, acting director of the health policy program at the New America Foundation and the author of “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.”

“Sometimes the test leads you down a path, a therapeutic cascade, where you start to tumble downstream to more and more testing, and more and more invasive testing, and possibly even treatment for things that should be left well enough alone.”

The entire article is here.

From an Ethics of Rationing to an Ethics of Waste Avoidance

By Howard Brody, MD, PhD
The New England Journal of Medicine
Originally published on May 24, 2012

Dr. Howard Brody

Bioethics has long approached cost containment under the heading of “allocation of scarce resources.”  Having thus named the nail, bioethics has whacked away at it with the theoretical hammer of distributive justice. But in the United States, ethical debate is now shifting from rationing to the avoidance of waste. This little-noticed shift has important policy implications.

 Whereas the “R word” is a proverbial third rail in politics, ethicists rush in where politicians fear to tread. The ethics of rationing begins with two considerations.  First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.

The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too. The ethical argument about rationing then shifts to the question of the fairest means for allocating scarce resources — whether through the use of a quasi-objective measure such as quality-adjusted life-years or through a procedural approach such as increased democratic engagement of the community.

The entire story is here.

An interview with Dr. Brody is here.

Thanks to Gary Schoener for this lead.