Monday, July 21, 2014

A physician does not need to be society's steward to "Choose wisely"regarding medical advice

Eliminating dangerous and unnecessary medical tests and treatments is the ostensible aim of the "Choosing Wisely" ( CW) initiative that is being promoted by the American Board of Internal Medicine Foundation (ABIMF).

I submit that is is not only unnecessary to evoke the principle of physicians as stewards of society's medical resources to accomplish that goal but it is a dangerous concept and promotes the idea that the individual exists to further the welfare of the collective or " society" Even the most cursory study of world history in the 20th century should disabuse one of the notion that such an approach works out well.

If a physician strives to do what is right for the patients,not to harm the patient and respects the patient's autonomy no other ethical principle is necessary to achieve what the choosing wisely campaign purports to accomplish. Following century's  old  medical ethics it all that is required. A physician so directed would not knowingly order tests or treatments that are harmful to the patient or useless and thereby waste the patient's money, whether or not all or most  of the reimbursement is from an insurance company or the government.The physician by choosing wisely is not saving some mythical society's resources but is spending less of a particular entity's money.

It is not necessary to compare  spending patterns per capital in various countries to cajole physicians to reduce or eliminate  tests or treatments that are useless and or harmful. It is not necessary to change the culture of medicine which has been the announced aim of some spokesmen for ABIMS and ACP to get doctors to do what is right in their best judgment  for their patients.

When my family or I go to a physician I want her to recommended a test or treatment based on her judgement as to whether that would be in the bests interest of her patient and not based on some imaginary role as a steward of some mythical collectively owned resource.

 The folks at ABIMF have been very explicit about linking their version of social justice with the Choosing Wisely initiative.See here.  I submit that physicians have attempted to do what in their judgment is right for their patients without evoking the notion of social justice and that includes not harming the patient by ordering harmful procedures and treatment.Social justice as the term is generally used involves redistribution from the better off to the most disadvantaged. ABIMF's version of social justice is based on utilitarianism keyed to QALY ( quality adjusted life years) per dollar spent and seems to be obsessed with spending less money generally on health care.Think about that for a moment. In what other profession is there a well funded campaign to spend less on what members of the profession have much of their lives learning how to do? Cui Bono.

Being a physician is not the easiest job in the world.It continues  to be true that life is short,the art long, opportunity fleeting, experience treacherous and judgment difficult. My physician has enough to do without assuming the pretense of being a steward of anything-her fiduciary duty to her patient is more than adequate.

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