Tuesday, January 17, 2012

Is the American College of Physician's new Ethical Manual an ethical game changer

Dr. Michael Kirsch, author of the blog, MD Whistleblower, thinks so; see here for his view.

Here is a money quote from his commentary: He begins with a quotation from the ACP Ethics Manual;

Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly.

This is an ethical game changer. According to the updated ethics manual, physicians should consider preserving health care resources for the population at large, which may conflict with our patient’s interest. Now, we are told that we are ethically obligated not only to advocate for our own patient, but also for hundreds of millions of other patients. If this becomes standard operating procedure, how will it impact the doctor-patient relationship? Will patients, who are increasingly skeptical of the medical profession, trust us? Will they suspect that we are restraining their care to serve the greater good?

The camel's nose (along with other anatomical parts) that sneaked under the medical ethical framework tent was the publication of a physician's" Charter" (aka New Professionalism) which in a gigantic non sequitur gratuitously asserted that social justice was now a major element in what they said what was medical professionalism, stopping just short of explicitly saying it was part of ethics.However, it was not clear what the separation between professionalism and ethics really was. Now the ACP makes that final move equating social justice with preserving health care resources for everyone and somehow balancing that against the individual patient's interest as an ethical responsibility. Has the concept of fiduciary duty to the patient really been shoved down the memory hole?

This is an ethical game changer but sometimes the ACP spokespeople seem to write and speak about both the charter and the ethics manual as if nothing has really changed. For example, I offer the following quote from recent comments from the president of the ACP, Dr. Virginia L. Hood in her message printed in the ACP Internist of January 2012.

She refers to the 2002 publication of a "physician charter to confront the health care challenges of a new millennium ". She continues " As well as restating (my bolding) the principles of 'primacy of patient welfare,patient autonomy, and social justice' ,it outlined a set of professional responsibilities..."

The charter did not restate social justice;it gratuitously inserted it and certainly never explained how striving for social justice enabled physicians to confront the new challenges. Now Dr. Hood writes about it as if social justice had always been a key element of medical ethics. It may be a useful rhetorical tool to just assume away a controversial issue but it should be clear that social justice based on a utilitarian calculus to allocate health care " resources" was when the charter was published and continues to be a source of considerable controversy in the medical community.

In a 1988 Annals of Internal Medicine Article,Hall and Berenson made- what appeared to many of us who were raised medically with the "old" medical professionalism of fiduciary duty to the patients- a startling proposal:

"We propose that devotion to the best interest of each individual be replaced with an ethic of the best interest of the group for which the physician is personally responsible."

Dr. Edmund Pelligrino writing in 1995 asked in the ethics of a profession could be changed at will.

Judging on the basis of the New Professionalism and the statements in the recent ACP Ethics Manual, it seems like it has.

DrRich of the blog "The Covert Rationing blog also believes it is a game changer.Further he offers his view as to what the real import of the new ethics is in this passage:

And here is the real import of the updated Ethics Manual. It aims to assuage the guilty conscience of physicians who follow handed-down guidelines to the letter, even against their better medical judgment, instead of tailoring the application of those guidelines to the benefit of their individual patients'

Exactly. It is an 180 degree switch from the antiquated ,fuddy duddy "fiduciary duty" silliness of a by gone era.

The ethical physician of today (again quoting DrRich) is "to follow the best evidence , in particular the best evidence on cost-effectiveness" and

" it is now the ethical obligation for doctors to follow expert produced guidelines" ( see here for DrRich's full commentary).

It is of some interest (or irony) that the introductory section of the 6th edition of the American College of Physicians Ethics Manual was written by an attorney, Lois Synder and there was no mention of a physician's fiduciary duty to his patient .

I do have trouble reconciling the words of the manual-particularly those quoted above-with these comments regarding the new manual from Dr. Hood as quoted in the 1/11/2012 Modern Medicine, on line:

“We have to consider cost as one of the factors when we make medical decisions, because that’s in the best interest of our patients,” Virginia Hood, MBBS, MPH, FACP, an internist and nephrologist and president of the ACP, tells eConsult. “It shouldn’t ever be an overriding part of a decision, but physicians need to take it into consideration.”

She continues:We have been advocating for efficient care since 1984, but it’s been given a slightly greater emphasis because the costs of care are so much higher,”,

So what is it- a slightly greater emphasis on cost or a real ethical game changer in which the fiduciary duty of the physician to the patient is not mentioned. Dr Hood's words quoted above seem reassuring but the black letter words as written in the ethics manual seem to pit the needs of the individual against the nebulous and ambiguously defined common good. In "box no.4 which addresses "Patients First and stewardship of resources" it says in part there is a responsibility to provide "parsimonious care that utilizes the most efficient means" [for diagnosis and treatment] . That sounds to me to be more than a slightly greater emphasis.

Also seemingly contrary to the representation that the new ethics manual really does not represent a major shift are several comments found in the editorial by Dr. Ezekiel Emanuel.(3 January 2012,Annals Internal Medicine,volume 156.number 1.pg 56)

Emanuel says :"Here is a professional society unafraid of advocating the principle of cost-effectiveness." Here aren't we talking about stuff like amount of dollars per life year saved?

He continues :These positions on efficiency, parsimony and cost effectiveness constitute an important shift,if not in ethics , then in emphasis." and

"It goes well beyond the usual banalities to take brave stand on current issues".

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