Saturday, June 16, 2007

Old wine-new bottles-you have to be a doctor to the whole village?

Dr. David Eddy authored a series of articles in JAMA ( Eddy DM. Rationing resources while improving quality.How to get more for less.JAMA.1994:272,817-824) promising to tell the great unwashed cadre of trench dwelling physicians how they could increase quality and save money at the same time. The trick was the utilitarian imperative-do the greatest good for the greatest number. In his moral calculus it was not only appropriate but it was ethically demanded that, for example, one would not waste money by for example offering yearly mammograms to women between 40 and 50 if a greater bang for the buck could be achieved by offering smoking cessation session to pregnant women. Cost effectiveness analysis was to guide what was offered to the group It was the health of the collective that mattered and that was true even if the collective was a thrown together bunch of strangers whose employers happened to sign up to a given HMO. The traditional fiduciary duty of the doctor to the patient as well as the legal manifestation of that relationship and the aspect of human nature that says I want what is best for my health and my family's health not for some alleged aspect of a fictional collective would have to moved past and we would be on the road to the solution for all that ails American medicine and health care. Doctors should not be hoarding resources for their patients.

Policies create winners and losers , a point that Dr. Eddy did not deny.He spoke of the consequences of "allocating a limited pool of resources to maximize the health of all of the people[in the]pool"even if that meant some would loose out on a benefit. The argument that the "insurance pool" or HMO population or some other organizational collective would gain if the net gains would outweigh the net loses is to endorse a utilitarian ethic but also relies on the cost-benefit assumption that everyone is the same so that costs and benefits can be appropriately aggregated.

In a recent JAMA commentary, the President of the American College of Physicians and the Chief Medical Officer of Aetna ( Dr. Christine K Cassel and Dr. Troyen E.. Brennan) expound on how the ails of American medical care can be remedied. Their exposition seems to me a rehash of Eddy's series although I missed where the authors admitted that there are some who would loose out in the collective cost benefit analysis driven policy decisions.(JAMA ,June 13, 2007, Vol 297, no. 22, p. 2518, "Managing Medical resources.Return to the Commons"

They speak of an abstract hypothetical " medical commons" and how the current emphasis by the physician on the welfare of the individual patient will spoil the commons much as the farmer who selfishly grazes his cattle on public land without regard for depleting the resource will destroy the resource.Physicians are implored to "reconstitute the medical commons" and think in terms of resource conservation and allocation so at the end the greatest medical good can be done for the greatest number of patients.They admit there is not currently such a commons. There never has been so I am unsure how a return is possible.

The medical commons figure of speech seems particularly lame.While a grassy knoll for the villager's sheep can be defined by a specific surveyor description, the "medical commons" is a extremely large amorphous array,the elements of which almost defy enumeration, and every changing, with some elements growing ,others contracting and innovations cropping up constantly.There is no easily defined entity called "medical resources";it is an amorphous abstraction.Further, to speak of allocation means some one or some elite group will be the "allocator in chief ". Decisions will not be made by thousands of individual physician-patient pairs.

Cassel and Brennan assert that a market based or a regulatory approach will allocate resources without the caring and wisdom that clinicians can bring to the endeavor. In their analysis the only choice is a medical commons with physicians and patients moving hand in hand willing to put aside the petty concerns of the individual when necessary for the greatest good of the group.Collectivism has been so successful in the past, why would it not work here?

Does American medicine have many troublesome problems? Yes, it does. I cannot see a rehash of Utilitarian ethics and a very bad analogy and some pie-in-the sky medical collective farm fixing much of anything.

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