“Bedside Rationing”: Is It Ethical? Would It be Effective?
There has been much discussion in recent years about “bedside rationing”. These discussions really involve the issue of what is the ethical role of the physician. Is it to provide the best treatment to the patient with only the patient's beneficence in mind or is it also to consider the societal implications of medical care and to withhold certain treatments to specific patients because of costs or scarcity, thus perhaps providing beneficence to society in general? After all, one may argue, that it is society who has given physicians their special privileges and therefore physicians should also be responsible to society.
In an excellent journal review of the issue of bedside rationing, Renee Witlen writing in Virtual Mentor first considers the views of P.Ubel, R,Arnold "The unbearable rightness of bedside rationing: physician duties in a climate of cost containment".( Arch Intern Med. 1995;155:1837-1842). She then presents opposing views. Here is an excerpt from the beginning of the Virtual Mentor article. I would strongly advise my visitors to click on the link above to read the entire piece.
In their 1995 article, 'The Unbearable Rightness of Bedside Rationing: Physician Duties in a Climate of Cost Containment,' Drs Peter Ubel and Robert Arnold assert that physicians should engage in bedside rationing in order to contain rising health care costs. They define bedside rationing as 'physicians"actions to withhold beneficial care from patients that physicians were free to offer them" and confine their discussion to rationing done "either without patients being aware of the rationing or, less often, with patients being aware but being given no choice". Many physicians and ethicists have rejected this role for physicians in the belief that physicians must advocate for the individual patient, even acting, if necessary, against the "apparent interests of society as a whole". Ubel and Arnold contend that if bedside rationing is conducted correctly, it is morally acceptable and, in conjunction with rationing decisions at higher levels of health care organizations, constitutes the only viable way to contain health care costs in the short and medium term.
Do you think that bedside rationing is fair and would be effective only in countries that have national health plans, where there is a more uniform allocation of healthcare resources as compared to our USA private/governmental forms of healthcare delivery? Let me know what you think. ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:17:00 PM
14 comments
14 Comments:
If physicians are to begin making decisions about patient treatment on the basis of cost, economic justification, and societal good, isn't physician education going to need to change dramatically so that docs can make informed decisions? Frankly, I think that physicians have their hands full being the best doctors they can be. Let docs be docs. We should remember that there are other professionals.
It's one thing to ponder such lofty ethical ideals and to debate the physician's role in rationing but it's quite another thing to expect this to happen in actual practice.
Physicians (some, not all) are very aware of the enormous costs on society of expensive medical care but I can't believe that any doctor would start practicing medicine by making treatment decisions based on the good of society rather than what is good for the patient. Such rationing would only occur in an extreme situation such as a disaster where medical supplies are low and critical treatments would be given to those victims with the best chance for survival.
The kind of rationing that goes on in countries with nationalized health care systems appears to be more a function of the system rather than of individual physicians on a case per case basis.
But this is not to say that rationing in our health care system is not an important issue or option. Everyone in this country complains about the costs of health care but everyone also expects the system to "spare no expense" when it comes to treating them and their family! Curious JD recently commented on my blog about friends of his who racked up over $300,000 in medical bills to care for their extremely premature infant. The insurance covered most of this but these costs will be then passed on and spread around to the other policy holders as increased premiums and as these go up the number of patients who will no longer be able to afford this coverage will also go up. Can we or should we try and save every single premature infant no matter how poor the prognosis or the likelihood that it will survive only with severe disabilities? This is not just an ethical issue but an economic one. How many people will not be able to afford health insurance because we will be spending hundreds of thousands or millions on dollars on patients both old and young who have little chance of survival (or who will be left with a very poor quality of life).
Will physicians be given wider power to unilaterally limit treatment in cases where the prognosis is poor and the expense of this care is not justified? Not anytime soon given our current litigation environment
PS; Before anyone accuses me of being a Nazi, I am not advocating euthanasia, infanticide, or policies to do away with the old and infirm. My point was merely to get people to start thinking about exactly why health care costs are so high and the issues of rationing in health care.
I agree that bedside rationing will not be followed by physicians as standard operating procedure in the forseeable future. This is because the physicians have never been trained to look much beyond the patient to whom they are duty bound to protect. Further, the medical world is now a "consumerism" world with the previous physician paternalism now suppressed. Patients are not going to agree to give up, in their eyes, important tests or treatments in order to pass on the savings to whoever. And finally, there always hangs the sword over the physicians' heads of malpractice suits by those unhappy consumerism patients. It will take legislative action to force patients and their physicians to do bedside rationing (as Oregon's Medicaid program has done)for this concept in medical care to be uniformly carried out. ..Maurice.
It's kind of freaking me out reading the doctors' statements. As a patient finding it hard to get any kind of information lately, I think I'm face to face with these attitudes of 'rationing'. It almost seems like we are being rationed out of any treatment at all. I agree that physician 'maternalism' is suppressed but I don't think it's by 'consumerism patients'. I guess this really bothers me most because it is my family that will suffer under policies like these. The insurance companies don't seem to be hurting all that much though. And the drug companies can spend millions of dollars advertizing directly to patients, who then, trying to alleviate their suffering from the doctors rationing, will march in and demand the drug, which of course will be given to them because the more patients buy drugs, the more money the drug companies have to spend to send doctors on 'educational trips' to learn about the new drug they are peddling. Do I sound completely obnoxious? Sorry but I just stumbled in here, read the posts and felt compelled to respond. I am not the type to EVER sue some doctor for a mistake or problem unless it was purposefully (and I mean completely obviously) harmful. Would any doctor care to post how many times they personally have been sued? You hear alot in the media about frivolous lawsuits, but isn't there a better way of handling this problem? So the insurance companies charge us alot of money for insurance, a doctor makes a big mistake for which a patient feels entitled to compensation for injury, for which the doctor has to spend a million dollars for insurance for... who's getting rich off this? And so the doctors have to drive up prices to afford insurance and therefore the poorest of us can't afford to go to the doctor and then just die in our homes. This seems very classist to me. I do however admit to being on the lower middle rung of society, hence my dismay about where all this is headed.Cancer patients defy doctors odds all the time. Do doctors now get to ORDER these patients to die? I am thinking about how these health care costs are becoming so high, I guess I'm just not coming to the same conclusion. Whats the point of working so hard to get people healthy and living longer if we're just going to randomly choose which patients will die ( and let's face it, it won't be so random, it'll always be easier to let that poor lady with not much health coverage's preemie die). I guess at least have it be under a national health plan, one where even if you had enough money to buy the drug outright, it could possibly be given to someone else. But maybe that's just what you meant when you said 'the best chance of survival', whoever can pay the most.
I honestly didn't mean to come off totally rude. It's just distressing to me to pass from predominantly patient websites where they are all desperately trying to figure out how to treat themselves and their children for serious illness, to a place full of doctors having this conversation.
To Anonymous: I can understand your point of view and as representing the patient, our medical care system must be frustrating in the various areas you described. I can tell you it is also frustrating for the physician.
Health care costs could be reduced and distribution of health care could be improved by changing some behaviors going on now. First, the drug companies are clearly currently receiving enough income to support needed research and development to continue to produce helpful medications for patients. If spending for direct to consumer advertising and physician gifts were eliminated even more money would be available for research. If actions of "clinics" offering potentially harmful and useless tests and procedures such as "whole body" CAT scans were stopped, costs would be reduced. If the public were better educated in what current medical science can (and not through drug company ads or TV dramas) but also cannot accomplish, the public would have a more realistic mindset and would be less likely to try to pressure physicians into prescribing tests or treatments that are expensive and not appropriate. In the same way, there should be encouragement of education of the public and discussion regarding ethical and legal issues involved in medical care, medical decisions, balancing benefit vs burdens and particularly related to terminal illness and end-of-life issues. This also would provide families, despite their understandable emotional upset, with a more realistic view of what really is occuring to their ill loved one.
Having potential malpractice cases routinely screened before coming to trial to eliminate those which are clearly fivolous would also reduce costs but also make it less likely that physicians would make poor and expensive medical management choices because of fears of malpractice.
What I am getting at is that there is much which could be done which could provide the potential for cost containment without subjecting the physician to the burden of making such decisions at the bedside. ..Maurice.
Maurice, I think you've left out one of the cost-savings measures that fit directly into your bailiwick: doctors need to step up to their ethical responsibilities and deal with the admittedly small number of very bad docs within their midst.
Dave, doctors are encouraged to report their impaired colleagues who need help because of mental or behavioral problems or suspected drug abuse to hospital committees whose specific function is to discuss and direct these doctors to help resources. For those doctors who fail to attend to standards of practice, make too many errors or fail to attend to continuing education, have too many malpractice suits, sexually misbehave with their patients or have criminal behavior, the state medical boards are responsible to do something about them. Of course, it is the responsibility of both the patients and other healthcare providers who observe these doctors to report them to the boards. The "bad docs" are obviously not saving costs but I doubt they are the major cause of the cost of medical care. The factors I noted in my last post are probably more significant in this regard. ..Maurice.
By Thomas R. Reardon, M.D., AMA President
The American Medical Association (AMA) is deeply disappointed that a slim majority of the U.S. Senate has decided to deny the American public the fundamental right to the health care they need when they need it. In a highly regrettable action, the Senate has bowed to the insurance industry dictate that says their profits come first and patients come last.
This excerpt was from the 'Medical Reporter' or something. This statement was followed up by some comment about the American public being too smart to let this happen. Apparently this doc hasn't been outside his house in a long time.
Anyways, I guess what I'm thinking is why are putting caps on people's lifespans and denying people diagnostic tests to keep 'costs' down? It seems to me that your general insurance paying public is the bottom 90% of household incomes. It's so wrong to me that when people can't afford heathcare without someone's income coming down, that it's going to come out of the pockets, or the lives of already poor people, just so the top 2% can stay disgustingly rich. But I guess if the insurance companies are paying most of the doctors' salaries, you're not going to find too many doctors disagreeing with how the insurance companies work. I think I'd rather just pay a doctor $200 a visit (or however much it requires to keep them in the lifestyle they are accustomed to) then pay insurance for tests and procedures. At least then it would take doctors out of the ethical dilemma loop. I'm really thinking that all this whole tort reform thing is going to do, besides take a couple of ridiculous lawsuits out of the system, is release all doctors from accountability. For a large number of them, it won't matter, they'll still do their jobs. But I can think of a few who don't need any encouragement.
I actually have a positive attitude toward euthanasia that is self administered, although I recognize the impossible legal issues that would go along with documenting that type of thing. If someone is old and tired and in pain, let them die if they want. But if medical science can allow an old person who is not ready to die even a couple more hours with a loved one or whatever, who is the authority who will force them to die? We save people with supposedly terminal illness every day (well, ok, you do). Why are those people's living hours more important than those of a very old person, whatever their reason for wanting to stay alive is?
My grandmother died last year in the ICU. When they admitted her to the hospital with breathing difficulties(she was not doing so well, mentally or otherwise) they didn't check her chart there and administered a drug that she was known to be severely allergic to.(ok, so I'm not a doctor, but I remember it was some med that was definitely not necessary to survival, even if the doc thought she needed it or something) Right after it was administered, her kidneys shut down. (She had been intubated upon arrival) Now, most of the communication between us and the Doc was done by way of the nurses who were all fruitcakes. But immediately after being intubated, they were already talking about if this was going to be the end of her life (the nurses, that is), because every time they tried to take the tubes out, she couldn't breathe on her own. So what happens next? The doc decides that they are going to put her on dialysis. I don't know if they were hoping she'd die during the surgery or that she'd live through it to prove that the medication mistake wasn't that bad. However, she lived through the surgery and a couple days later, after trying a couple more times to take the tubes out, they made the decision to start talking us into letting her die. Which of course we did because we knew her and knew that she would not want to exist this way. But the doc and nurses conversations with us didn't educate us about anything. All questions about her condition had to be asked VERY firmly or they wouldn't be answered. Most of the conversation was centered around them telling us thet she wouldn't want to live this way, which, of course, was just about the only aspect of the situation that they weren't an authority on.
Now, I know that this situation is merely anecdotal evidence and therefore doesn't mean anything, but it kind of illustrates a couple of the points of these posts. I don't know much about the costs of certain procedures but I imagine dialysis is pretty pricey. Where was the cost containment here? I bet you anyone looking in from the outside would say, well how ridiculous, putting a person on dialysis right before they take them off life support. But we weren't given the choice at all. The family's conversation had already turned to whether grandma wanted to live with tubes down her throat in some nursing home. We would have made the same choice to remove the tubes either way.
So we would have made that decision for her, but I also had a premature baby myself, maybe only two weeks premature, but there were complications nevertheless. You put me in a situation like the one Chris described, you can take the $98 fuzzy slippers, the peribottles and all the stupid crap they roll into the hospital stay that they charge the insurance companies for and shove it up you know where cause I don't care how little my infant's life means to Joe Schmoe, you are going to save that baby if you can, forget the lawsuit, it'll be at peril of your life. (Does that sound extreme?)
There were probably at least four different lawsuits involved in my grandmothers passing, but sometimes things just happen and I think you have to account for chaos. Although there were definite mistakes made, I don't think there was malice and that's what matters to me. So if we didn't even look into suing, how many more are like us? Seems to me like if you'd just give people the facts and let them make an informed decision, they wouldn't feel like there's some massive conspiracy out there to just let them die no matter what. Let the family decide the 'benefits vs. burdens' and you'd probably find people alot happier with their healthcare and I bet the costs wouldn't go up that much. (But if they do take them out of the insurance profits! Sorry, the communist is talking again!)
I can solve the problem of a few bad doctors driving up your malpractice insurance though! I'll waive the right to sue doctors for criminal or sexual (mis)behavior if we can put in a clause that gives us a right to give them a good, hard smack upside the head for that behavior. Although I recognize the fact that there will be no accounting for misunderstandings...
Gee, this post is obnoxiously long. Sorry.
This is a very interesting topic.
I was stimulated to post about a specific example on my blog http://doctorandy.blogspot.com/
My general take is that it is best to take docs out of the process of rationing care, at least for the most part
Doctor Andy
This is an important issue in medical care and one that does threaten the integrity of our profession. Although it is far from the be-all and end-all of medical ethics, the Hippocratic Oath represents some important principles, and one of the most important is the fact that the ethical physician acts for his/her patient's benefit, and not to please some third party. "Rationing at the bedside" is inherently unethical. The chairman of the Medical Ethics Department at the New York Medical College, Dr. Daniel Sulmasy, MD PhD OFM, has written on this subject, and you will not regret perusing his thoughts. When the "medical professionalism" project was launched at the A.C.P. Annual Session in Atlanta a couple of years ago, I argued strenuously against the statement that physicians should take the "interests of society" into consideration when deciding on how to take care of a patient. Our patients expect us to do what is best for them, and not what is best for "society." This is the same lie the statists and socialists always use to justify the power they seize and the property they confiscate: we're going to take away from you, as Senator Clinton recently threatened a group of Democratic donors, "for the common good." Except that "the common good" and "society" are abstractions. What really excites the statists is the idea of taking away, seizing, and gaining power. The A.C.P. professionalism paper was cribbed from European examples, and the Europeans are already corrupted by ideologies which deny the value of the individual. Thankfully, the final language was adjusted, as far as I can tell from the versions of the documents currently posted on the A.C.P. website, and doctors are no longer being exhorted to deny care that patients need so as to save "resources" for "society." An individual doctor caring for an individual patient must never ration care at the bedside. Would you go to a doctor who advertised that he might withhold care you needed, simply because he thought you weren't deserving?
I can certainly agree with the view of the last Anonymous writer and I intend to try to find and read the document on the American College of Physicians website which was mentioned in the comment.
****
Might I suggest to those who choose to remain anonymous, that you at least post a "screen name" to identify yourself amongst all those "anonymouses". Hopefully, those who write to this issue will have enough ethical behavior not to participate in "identity theft" by posting with someone elses screen name.
..Maurice.
Dr Bernstein, you are right about the infelicity of anonymous comment-posting, and I will remedy that situation as soon as I can. In the meantime, here is the URL to the ACP Observer article which described the original professionalism language. That language has been changed, I think, in the current document.
http://www.acponline.org/journals/news/jul01/professionalism.htm
Bedside rationing is not a sufficiently precise term upon which to have meaningful discussion in my opinion. We make patient-by-patient limitations in health care every day for a variety of reasons, many of which do occur at the bedside whether we want to admit it or not. We decide when and where to transfer chronically ill patients in large part because of their insurance status. We withhold care in one tiny baby because we think it's futile and their parents agree and spend millions on the next because the parents don't (regardless of fiscal issues). We choose antibotics based on cost, or not because of their potential for their ability to create a super resistent strain and whether or not they are in short supply and needed by other at risk patient subsets. It's all "bed-side" rationing. Is it right or wrong? Pointless. Its here. If we're already doing it and that's someone's principle argument against a national health care system...time for a fall back position.
Dr Phillip V. Gordon MD PhD
author of Cherubs in the Land of Lucifer (@ Cherubsinthelandoflucifer.com)
I couldn’t agree more with the anonymous comments of Wednesday, February 23, 2005:
"Seems to me like if you'd just give people the facts and let them make an informed decision, they wouldn't feel like there's some massive conspiracy out there to just let them die no matter what."
-But he hasn't a clue how easy he got off with his grandmother. When we talk about "bedside rationing," not offering a family the full array of options, we're really talking about covert rationing. For the big ticket (and money-losing in today's economy) items like dialysis or intubation, covert rationing entails withholding as long as possible in the hope the patient will die before it becomes a clear (standard of care) issue.
And what happens when the family figures out what’s going on midstream, after a covert rationing decision has already been made? Do the doctors stop and reverse course?
Please take a look at what happened to my father. My story is anecdotal, but the record is not.
http://users.starpower.net/neustadter/menu.html
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