By Jennifer Popik, J.D., Legislative Counsel for the Powell Center for Medical Ethics at the National Right to Life Committee

Jennifer Popik, J.D. Robert Powell Center for Medical Ethics

Earlier this week the largest group of specialist physicians in the United States issued controversial revised “ethics” guidelines stating physicians have a “responsibility” to limit the treatments they give their patients in the name of saving health care resources for others.  

The American College of Physicians (ACP), comprised of over 130,000 doctors who specialize in internal medicine,  is the second largest physician group in the nation; only the American Medical Association has more doctors as members. 

At the heart of the controversy is a provision of the sixth edition of it Ethics Manual , described at www.annals.org/content/156/1_Part_2/73.abstract, that states:

“Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

The word “parsimonious,” meaning sparing or frugal to the point of stinginess, has generated the most buzz.

ACP President Dr. Virginia Hood gave an interview to National Public Radio’s “All Things Considered” [www.npr.org/2012/01/02/144591018/physicians-group-weigh-costs-in-treating-patients]. The host, Melissa Block, introduced its report by observing that “the group takes a provocative position.”

Hood told NPR reporter Rob Stein,

“We also have to realize that if we don’t think about how resources are used in an overall sense then there won’t be enough health care dollars for our individual patients. So while concentrating on our individual patients and what they need, we also to think on this bigger level both for their benefit and for the well-being of the community at large.”

NPR offered a dissenting view from Scott Gottlieb of the American Enterprise Institute. His remarks and Stein’s comment are as follows:

GOTTLIEB: Saying that the use of resources should be parsimonious – that implies a whole lot more. I mean, that really implies that care should be withheld.

STEIN: And Gottlieb says that phrase raises fears of doctors withholding care without even telling patients what they’re doing.

What is additionally troubling about the guidelines and the follow-up from the ACP is the acceptance of the popular misconception that Americans cannot afford health care.  Although it may seem counterintuitive, as a society, Americans CAN afford health care, even going forward. For a webinar on how, see here http://nrlcomm.wordpress.com/2009/06/13/hcrwebinar/.

To ensure that the “safety net” can be financed without rationing the National Right to Life Committee has  proposed that health insurers  provide their fair share of basic health insurance policies to those the government determines will otherwise be unable to afford it at sliding scale discounts varying with income and assets. Insurance companies would take into account the need to finance these required discounts when setting their premium prices, just as hospitals now have to take into account the need to finance undercompensated and uncompensated care in their emergency rooms when setting the prices for their services.

This would mean that the level of health care for all would effectively be set by the collective decisions of many citizens (and employers) deciding what premiums they were willing and able to pay for health insurance, with the cost of covering the uninsured taken into account in those decisions. The level of health care provided would never exceed what the economy as a whole could afford, but neither would it be held, by government constraint, below what Americans would freely choose.

As productivity increases across the American economy increase the level of available health care on average, the health care available to those otherwise unable to afford it would change with it. A rising tide really would lift all boats.

Instead of the collective decisions of the public, the ACP dangerously proposes to ethically obligate doctors to be stingy with treatments, irrespective of an ability or a willingness to pay for the life-saving care.  This large and influential organization neglects the fact  that America as a whole  can indeed afford more and better healthcare, decade after decade.   And the ACP’s new Ethics Manual edition undermines the most fundamental ethical obligation of a doctor –to put the patient first.

The traditional role of the physician has long been considered that of an advocate devoted to the interest of the patient.  Indeed, an article in the Annals of Internal Medicine explaining the new Ethics Manual edition states, “The physician’s primary commitment must always be to the patient’s welfare and best interests, whether in preventing or treating illness or helping patients to cope with illness, disability, and death. . . . The interests of the patient should always be promoted regardless of financial arrangements . . . .”

Despite this acknowledgement, by making the physician into a rationing agent, expected to limit treatment for one patient  “to help ensure that resources are equitably available”  to other patients, the new ACP Ethics Manual changes doctors’ primary allegiance away from the individual patient to the state.