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Choosing Wisely: Is Parsimonious Care Just Rationing?

  • LEONARD M. FLECK
Abstract:

The American College of Physicians in its ethics manual endorsed the idea that physicians ought to improve their ability to provide care to their patients more parsimoniously. This elicited a critical backlash; critics essentially claimed that what was being endorsed was a renamed form of rationing. In a recent article, Tilburt and Cassel argued that parsimonious care and rationing are ethically distinct practices. In this essay I critically assess that claim. I argue that in practice there is considerable overlap between what they term parsimonious care and what they define as rationing. The same is true of the Choosing Wisely campaign endorsed by the American Board of Internal Medicine. In both cases, if the goal is to control healthcare costs by reducing the use of marginally beneficial care that is not cost effective, then a public conversation about the justness of specific choices is essential.

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References
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Notes

1. Snyder L (for the American College of Physicians Ethics, Professionalism, and Human Rights Committee). American College of Physicians ethics manual: Sixth edition. Annals of Internal Medicine 2012;156:73–104, at 86.

2. Tilburt, JC, Cassel, CK. Why the ethics of parsimonious medicine is not the ethics of rationing. JAMA 2013;309:773–4.

3. See note 2, Tilburt, Cassel 2013, at 773.

4. See note 2, Tilburt, Cassel 2013, at 773.

5. Keehan, SP, Cuckler, GA, Sisko, AM, Madison, AJ, Smith, SD, Stone, DA, et al. National health expenditure projections, 2014–24: Spending growth faster than recent trends. Health Affairs 2015;34:1407–17, at 1411.

6. There is an alternate interpretation that is advocated by Republicans in the United States that would free physicians from this moral responsibility. It is that consumers (patients) should have full responsibility for controlling healthcare spending. All that is needed to accomplish this are economic incentives—namely, high deductibles on health insurance and/or high co-payments for specific therapeutic interventions—that would prompt consumers to make rationing decisions for themselves. Consumers, the argument goes, could then ask themselves whether it was really worth that much of their money to purchase the healthcare intervention recommended by their physician. Quite obviously, this is rationing by ability to pay. As I and many other medical ethicists have argued, this approach is ethically objectionable for reasons of both justice and compassion. See Unger L, O’Donnell J. Dilemma over deductibles: Costs crippling the middle class: Rather than pay so much out-of-pocket, many skip checkups, scrimp on care. USA Today 2015 Jan 1; available at http://www.usatoday.com/story/news/nation/2015/01/01/middle-class-workers-struggle-to-pay-for-care-despite-insurance/19841235/ (last accessed 21 Aug 2015).

7. See note 2, Tilburt, Cassel 2013. See also Cassel, CK, Guest, JA. Choosing Wisely: Helping physicians and patients make smart decisions about their care. JAMA 2012;307:1801–2. The Choosing Wisely campaign was initiated in 2012 by the American Board of Internal Medicine. The Board picked up on an idea discussed by Howard Brody that each medical specialty society identify five tests, treatments, or procedures in that specialty that tended to be overused and, hence, ought to be reevaluated with regard to appropriate use. See Brody, H. Medicine’s ethical responsibility for health care reform: The top five list. New England Journal of Medicine 2010;362:283–5. More than 50 national medical specialty societies have now endorsed this idea.

8. Krieger L. The cost of dying: It’s hard to reject care even as costs soar. San Jose Mercury News 2012 Sept 20; available at http://www.mercurynews.com/ci_19898736 (last accessed 21 Aug 2015).

9. Sheets, NC, Goldin, GH, Meyer, AM, Wu, Y, Chang, Y, Sturmer, T, et al. Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. JAMA 2012;307:1611–20. The primary reason for the difference in cost between these two procedures is that proton therapy requires constructing a $160-million building the size of a football field with walls 12 feet thick.

10. Berwick, DM, Hackbarth, A. Eliminating waste in U.S. health care. JAMA 2012;307:1513–16.

11. Emanuel, EJ, Emanuel, LL. The economics of dying—the illusion of cost savings at the end of life. New England Journal of Medicine 1994;330:540–4.

12. Welch, HG, Schwartz, L, Woloshin, S. Overdiagnosed: Making People Sick in the Pursuit of Health. Boston: Beacon Press; 2012.

13. Robinson, JG, Farnier, M, Krempf, M, Bergeron, J, Luc, G, Averna, M, et al. Efficacy and safety of alirocumab in reducing lipids and cardiovascular events. New England Journal of Medicine 2015;372:1489–99.Sabatine, MS, Giugliano, RP, Wiviott, SD, Raal, FJ, Blom, DJ, Robinson, J, et al. Efficacy and safety of evolocumab in reducing lipids and cardiovascular events. New England Journal of Medicine 2015;372:1500–9.

14. See note 7, Cassel, Guest 2012. See also Chien, AT, Rosenthal, MB. Waste not, want not: Promoting efficient use of health care resources. Annals of Internal Medicine 2013;158:67–8. In Europe, Switzerland has undertaken a “smarter medicine” campaign, spurred by Choosing Wisely. Gaspoz JM. Smarter medicine: Do physicians need political pressure to eliminate useless interventions? Swiss Medical Weekly 2015;145:w14125. For the UK, see Garner S, Littlejohns P. Disinvestment from low value clinical interventions: NICEly done? BMJ 2011;343:d4519.

15. Moriates, C, Arora, V, Shah, N. Understanding Value-Based Health Care. New York: McGraw Hill; 2015, at 11.

16. Elshaug, AG, McWilliams, JM, Landon, BE. The value of low-value-lists. JAMA 2013;309:775–6.

17. Winslow R. Cancer’s super survivors: How the promise of immunotherapy is transforming oncology. Wall Street Journal 2014 Dec 4; available at http://www.wsj.com/articles/cancers-super-survivors-how-immunotherapy-is-transforming-oncology-1417714379 (last accessed 30 Aug 2015).

18. The American Society of Clinical Oncology defined improvement in median survival between 2.5 and 6.0 months as minimally clinically meaningful benefits for most solid cancers. Ellis, LM, Bernstein, DS, Voest, EE, Berlin, JD, Sargent, D, Cortazar, P, et al. American Society of Clinical Oncology perspective: Raising the bar for clinical trials by defining clinically meaningful outcomes. Journal of Clinical Oncology 2014;32:1277–80. In another review article, researchers looked at all new cancer drugs that gained FDA approval from 2002 until 2014. The median gain in survival was only 2.1 months. Fojo, T, Mailankody, S, Lo, A. Unintended consequences of expensive cancer therapeutics: The pursuit of marginal indications and a me-too mentality that stifles innovation and creativity: The John Conley lecture. JAMA Otolaryngology—Head and Neck Surgery 2014;140:1225–36.

19. Millman J. The coming revolution in much cheaper life-saving drugs. Washington Post 2015 Jan 16; available at http://www.washingtonpost.com/news/wonkblog/wp/2015/01/16/the-coming-revolution-in-much-cheaper-life-saving-drugs/ (last accessed 30 Aug 2015).

20. Gomez-Martin, C, Plaza, JC, Pazo-Cid, R, Salud, A, Pons, F, Fonseca, P, et al. Level of HER-2 gene amplification predicts response and overall survival in HER2-positive advanced gastric cancer treated with trastuzumab. Journal of Clinical Oncology 2013;31(35):4445–52.

21. Ubel, P. Why it’s not time for health care rationing. Hastings Center Report 2015;45:1519.

22. See note 21, Ubel 2015, at 18.

23. Calabresi, G, Bobbitt, P. Tragic Choices. New York: Norton; 1978, at 1728.

24. In an early essay of mine I argued at length that DRGs represented a presumptively unjust mechanism for healthcare rationing because decisions about constraining costs and care were largely hidden from patients. See Fleck, LM. DRGs: Justice and the invisible rationing of health care resources. Journal of Medicine and Philosophy 1987;12:165–96.

25. Fleck, LM. Just Caring: Health Care Rationing and Democratic Deliberation. New York: Oxford University Press; 2009.

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