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Wednesday, October 16, 2013

ABIM Foundation reveals how physicians can further social justice

Older physicians,inculcated as they were with outmoded,no longer applicable in the new millennium, ethical principles might have wondered how they should put into practice the newest addition to the ethical pillars of medical practice.The new addition, of course is social justice.

Social justice is part  of the new professionalism and also of the new latest version of Medical Ethics as conceived  by the America College of Physicians.

Fortunately-for those puzzled doctors-there is an organization whose professed reason for existence is to "advance medical professionalism and physician leadership in quality assessment and improvement". We will be instructed about professionalism and also how to strive for social justice.When social justice was proclaimed as the third pillar of professionalism we were given a broad charge, ambiguous and lacking in operational details. Put simply- how do practicing doctor "do" social justice.

In the July 19,2013 edition of the Medical Professionalism blog we get the answer. We physicians are to bring about social justice through "just distribution of resources and stewardship of resources".

 As enlightening as this may be ,some of the older physicians wonder what is their definition of "just".  My intuition is that later we well be told ( we may well have been told that already) that just distribution is  the distribution that results from a cost effectiveness driven set of guidelines which just happens to be the same way that operationally the rank and file docs can be said  to act as stewards of resources.

Here is another quote from the ABIMF's blog that attempts to elucidate the notion of just distribution
  ( my bolding):

" While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited clinical resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost effective care. The physician’s professional responsibility for appropriate allocation of resources requires scrupulous avoidance of superfluous tests and procedures. The provision of unnecessary services not only exposes one’s patients to avoidable harm and expense but also diminishes the resources available for others."

Physician are admonished to strive for a fair and cost effectiveness allocation of medical resources.Presumably the allocation must be both. While the methods of cost effectiveness analysis are well known and explicit- though not without serious criticism- the term "fair" is as ambiguous,vague and without obvious operational details as is the term social justice and is as subject to varying meanings.

 Philosophers have thought much and written a great deal on justice and on fairness.There is much that two of the 20th century's most  noted philosophers disagree about but John Rawls and Robert Nozick seem in general agreement that utilitarianism did not conform with their notions of justice and fairness.  The utilitarian approach does not respect the separateness of individuals and it may treat individuals as pawns in some social scheme allegedly bringing about some hypothetical, aggregate good or utility.Utilitarian theory is basic to cost effectiveness analysis as benefits and costs are aggregated over a group of people and it is the group analysis that trump a given individual's benefit or loss.

The philosophical mavens at the ABIM Foundation presume to instruct physicians on proper professionalism by advocating cost effectiveness analysis and the "appropriate guidelines " that follow. So, in the formulation declared to the ethical law of the medical land physicians are to strive for social justice by being committed to develop guidelines for cost effective  medical care.

 Then the question is raised: is cost effectiveness allocation of medical resources socially just?Is the  recently crowned new ethical precept,social justice, actually  achieved by allocating medical resources by guidelines derived from cost effectiveness studies? The third party payers would be joyous if that link were accepted. That is a topic for later comments.I am still trying to get my thinking around the notion that cost effectiveness furthers social justice.

addendum: Minor editorial changes done on 6/8/14 correcting a few typos and punctuation issues.


Anonymous said...

Social justice is typically considered to be distributive justice.Explain how limiting medical care ( sold under the rubric choosing wisely) which restricts medical care generally would benefit the most disadvantages.Less care for everyone doesn't look like redistribution to me.

james gaulte said...

So how does not doing imaging procedures on low back pain further social justice? I struggle to see the link.How does not doing PSAs on anyone lead to redistributive justice? That seems to be treating everyone the same which is not what progressives favor as treating unequals equally still results in inequality which is the principal social problem which progressives strive to eliminate.Eliminating dangerous or useless testing is obviously by definition a good thing but what does that have to do with social justice?