ARTICLE IN BRIEF
Neuroethicists weigh in on a new paper, which promotes providing cost-effective care as an ethical imperative.
What is a physician ethically obligated to do by his profession? Is performing cost-effective procedures a question of right and wrong? The American College of Physicians (ACP), which boasts a membership of around 132,000 internists, took some bold steps in answering these questions in the sixth edition of their Ethics Manual, published in the Annals of Internal Medicine on Jan. 3.
Neurologist Michael A. Williams, MD, medical director of the Sandra and Malcolm Berman Brain & Spine Institute at Sinai Hospital of Baltimore, praised the manual for addressing head-on the critical subject of health care spending. “There's a lot of dispute as to why those costs are rising and how to control them, but the fact that there's a dispute doesn't eliminate from us a responsibility to look at ways to treat patients well at costs that are reasonable.
“I think where the ACP has stepped out is to say, ‘We do need to take [cost-effectiveness] into account on a deliberate basis, and not just research it for the interesting questions or answers that may be generated by that research.’ How do we turn it into something that is pragmatic and is beneficial both to patients and society?” he said.
In interviews with Neurology Today, experts in the fields of neuroethics and health services research proposed ways to move these recommendations into practice and policy.
One way to reduce health care spending, as the manual has suggested, is using the medical literature and informed decision-making to perform more cost-effective procedures.
Farrah J. Mateen, MD, fellow in the department of neurology at Johns Hopkins University, said, “I think that people equate cost-effective with saving money when really that's not its purpose at all.”
When you do a cost-effective analysis, Dr. Mateen, who is also the chair of the AAN Ethics Section, added, it should be a comparison of two interventions. “You're asking a question: is this new intervention both more effective and more costly or both less effective and less costly? Sometimes it's really about spending more money and then asking whether that value is worth it,” she said. This is where ethics comes in — deciding, is that incremental benefit worth it? And that, Dr. Mateen said, is where the physician should play a role.
Gary Gronseth, MD, professor and vice-chairman of neurology at the University of Kansas Medical Center, said that there is nothing controversial about asking physicians to make cost-effective decisions. “If a physician had two treatment options and they were equally effective and safe, and one was more expensive and the other was less expensive than the other, we would use the less expensive treatment.” The trouble, he said, is that we generally have no idea whether one is more cost-effective than another, leaving the decision up to the individual physician after counseling with the patient.
Essentially, the document is telling physicians: “if you can make the diagnosis with one test versus three tests, do one test,” said Dr. Gronseth. Dr. Williams, who is the former chair of the AAN Ethics, Law, and Humanities committee, said: “I think some people may look at the statements in the ACP Ethics Manual cursorily and perhaps come to the conclusion that it is suggesting that we have bedside rationing, and they are very clear in their manual that that's not the case.”
Though, Dr. Gronseth said that, in many cases, it would be perfectly appropriate to withhold care. “Sometimes in terms of cost-effective, nothing is more cost-effective than something if that something doesn't work.”
AN ETHICS MANUAL FOR NEUROLOGY?
There are certain complex ethical dilemmas and disease-related questions that are unique to neurologists. Dr. Mateen noted that, for example, the ACP does “make a nod to disorders of consciousness, but it's a small paragraph, which in summary says to defer to the surrogate decision maker. This is something that might be better explained in a document specifically targeting neurologists,” she said.
This is a really fantastic document but they couldn't cover everything, Dr. Mateen said. “It would be worthwhile for neurologists to start thinking about this effectively as a group and as a professional society and codify it and put it in print,” she said.
Dr. Gronseth disagreed. Neurologists do not need one overarching document, he said. Instead, they could benefit from subject-specific guidelines with attached sections on ethics. For instance, he said, we are working on a guideline for persistent vegetative state and related disorders of consciousness. Having a section that deals with ethical issues would be a very useful part of that guideline.
The AAN has a code of ethics and has for a long time, and that's the starting point for guidance for neurologists, Dr. Williams said. In addition, the AAN has a body of ethics policies and guidance (aan.com/go/about/position). The ACP may be the only society that brings a body of policy on ethics together in a single document versus having individual documents on different subjects, he added.
“Would it be nice if the AAN had an ethics manual like this? I would say, yes. If you ask me are we lacking because we don't have a manual like this one? My answer would be no,” Dr. Williams said.
In order to adhere to the ACP's Ethics Manual and improve cost-effective, high-quality practice, there are other steps that neurologists can take, experts told Neurology Today.
First, said Dr. Mateen, we must clarify what we mean by cost-effective and what our goals are. “I think the first goal is to be educational, to have some online modules, websites, or documents on what it means for neurological care. [Cost-effectiveness] is a method — so you can use it for anything, but you have to use it in a way that makes sense for the patient. Figure out which diseases do you want to prioritize and then which interventions, because otherwise you can end up with a lot of literature that doesn't affect patient care, and I think that's unethical too — just creating documents for nothing.”
The second step would be coming up with really good data on cost and on outcomes, she said, adding: it is especially important to observe these interventions in historically marginalized populations. Then, she said, you must be willing to act on the research with either lobbying or policymaking or other forms of activism.
“I think one of the questions for AAN leadership,” Dr. Williams said, “is whether the practice guideline methodology should also inquire about the cost-effectiveness of the treatments that are being evaluated.”
That would undoubtedly raise some debate, he said, because there are many different ways to look at the question of cost-effectiveness, but it's something that would be beneficial to members and to patients. However, he stressed, we must not do that in such a way that limits necessary care for patients or puts cost above the patient's well-being.
Dr. Williams talks about the need for physicians to consider health care costs and the difficult balance between treating uninsured patients and maintaining a practice. And he suggests strategies for putting cost-effective care into policy and practice. Tune in: http://bit.ly/xuUnNu.
Dr. Mateen expands her discussion on the ethics of cost-effective care, a physician's duty to treat the underinsured and uninsured, and a doctor's intrinsic role as teacher. Listen here: http://bit.ly/ACwKwg.
HIGHLIGHTS OF THE NEW ETHICS MANUAL FROM THE AMERICAN COLLEGE OF PHYSICIANS
What's new in the 2012 edition of the ethics manual? Here are some of the important recommendations:
* Stewardship of resources: The patient must always come first. “Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.”
* Advance care planning and surrogate decision making: Raise questions about advance care planning before an acute crisis, document care preferences, and assist surrogate decision making in fulfilling their responsibilities.
* Catastrophes: During a catastrophe, shifting principles guide the patient–physician relationship, the manual states. “Guidelines for the just delivery of health care during catastrophe developed jointly by physicians and governmental organizations should be available to assist decision making.”
* Treating the uninsured: Physicians have a “professional obligation” to do their “fair share” for the poor, uninsured, and underinsured. Dr. Gronseth said that this concept is already implicit for most physicians. “For example, I'm a hospitalist, and at least a third of the patients that I care for are not insured and are not able to pay. I think that the vast majority of — if not all — neurologists, end up in situations where they are doing that.”
* Physicians and social media: “Physicians who use online media should be aware of the potential to blur social and professional boundaries.” The same professional standards should apply both in the clinic and online.
* Physician-industry relations: The acceptance of any health care industry-sponsored gifts is “strongly discouraged.” “It is the individual responsibility of each physician to assess any potential relationship with industry to assure that it enhances patient care.”
* Duty to teach: Teaching is a responsibility of all physicians.
* Human subjects research: All physicians involved in research have an “independent professional obligation to satisfy themselves that those studies meet ethical standards.”
* Sponsored research: Scientists must make sure that data is available and evaluated independently of the sponsor.
Read the full document here: annals.org/content/156/1_Part_2/73.full.pdf.