Several years ago, I served as a panelist at a conference on health care ethics at a university-affiliated community hospital. The chief of orthopedic surgery asked my opinion of a proposal made to him by the hospital's chief executive officer (CEO).
The CEO explained that the hospital was losing money on hip-replacement surgery, because the payment the hospital received from Medicare, which paid for nearly all hip replacements, was less than the hospital's cost.
A major component of the cost was the price of the hip prosthesis. The CEO requested that the orthopedic surgeons use a much less expensive prosthesis in patients older than 80 years whom they judged to be unlikely to live 10 years or more.
He understood (and the chief of orthopedic surgery concurred) that the less expensive prosthesis was as good as the one then in use, except that it was less durable and more likely to fail 10 years or more after implantation.
The CEO argued that it was unlikely that very old patients would benefit from the greater durability of the more expensive prosthesis. If the chief of orthopedic surgery did not agree, the CEO would limit the number of patients who could undergo hip-replacement surgery at the hospital.
The chief of orthopedic surgery and his colleagues were community practitioners wholly dependent on clinical fees for their professional incomes.
As the cost of medical care in the United States has increased relentlessly over the past few decades, so has the chorus of voices recommending or demanding that doctors ration care in their offices and at the bedside.
Traditionally, medical ethics has required doctors to do what is best for their patients. Recently, ethicists, policy analysts, politicians, health care administrators in both the public and the private sectors, and -- most surprisingly -- physicians have argued that in clinical practice, doctors must serve two masters, their patients and the public good.
The latter is best served, so the argument goes, if physicians not only practice cost-effective medicine but also are willing to ration medical care. Although various definitions of medical rationing are used in the literature, by rationing I mean withholding effective medical care for the financial benefit of any party other than the patient.
The beneficiaries may be physicians themselves, health insurance companies, managed-care plans, or local, state, or national government.
Various justifications have been advanced for this reversal of traditional medical ethics. A doctor argues that rationing by physicians caring for individual patients is more precise and more easily modified than the rules of health insurance plans or government regulation -- for example, Oregon's regulation of its Medicaid program.
An ethicist concludes that in the current climate of fiscal scarcity, in which bedside budget balancing is inevitable, it is morally credible for physicians to limit the services provided to their patients. In doing so, doctors can still remain their patients' best advocates.
Two doctors state, "Although bedside rationing raises serious moral problems, these are outweighed by the important social goal of containing health care costs."
A professor of law believes that the taboo against bedside rationing is not justified on the basis of either ethical principles or actual practice and should therefore be eliminated.
Other analysts think that accepting the responsibility to ration care in their practices is advantageous to physicians, because it offers them more clinical autonomy than alternatives such as rules imposed by payers.
Rationing by doctors can take place along a spectrum of intent and clinical importance. At one end of the spectrum is the virtually subconscious selection of approaches in the routine care of patients that are almost as good as more expensive alternatives.
For example, a doctor may refuse to order a computed tomographic study of the head requested by a patient who has recurrent headaches but a normal neurologic examination, even though the diagnostic yield of the study, although very low, is not zero.
In the middle of the spectrum is the conscious selection of a treatment that is somewhat less effective and much less expensive than an alternative treatment, in order to reduce the cost of care for a patient with a serious medical condition. A doctor may use streptokinase in a patient with a myocardial infarction rather than tissue plasminogen activator, which is arguably a much more expensive and somewhat more effective thrombolytic agent.
At the other end of the spectrum is the deliberate withholding of life-preserving therapy to reduce medical expenditures. For example, a primary care doctor may decide not to refer an elderly patient with end-stage kidney disease to a nephrologist for long-term dialysis or not to inform a woman with advanced breast cancer that intensive chemotherapy with bone marrow rescue may extend her life.
Although no systematic data are available, it seems unlikely that many doctors ration medical care of their own volition in order to save money for the health care system at large or for specific public or private payers.
Some doctors may ration their own services to increase their incomes by reducing the time they spend with patients to less than what they themselves consider to be optimal. Most rationing by practitioners is probably performed in response to the incentives or disincentives provided by third-party payers, such as paying physicians on the basis of capitation, offering bonuses to physicians who keep the costs of care low, or threatening to dismiss those who do not.
Hospital staff committees and administrators can exert a similar influence on the way doctors practice -- for example, by pressuring them to reduce the length of stay for their patients to a period that is shorter than the physicians consider appropriate. Even in these circumstances, the individual practitioner ultimately makes the decision to ration the care of a specific patient.
In contrast, some forms of rationing are beyond the control of the individual doctor. For example, a managed-care plan may not cover organ transplantation, or the pharmacy committee of a hospital may decide not to include in its pharmacopeia an expensive medication that is marginally beneficial for specific patients.
My impression is that even though few physicians consciously and voluntarily ration care, the growing body of opinion, in both the professional and the lay literature, that supports rationing by doctors as necessary and ethical has strongly influenced physicians' attitudes and actions.
At the beginning of my tenure as chief of medicine at a city hospital in 1968 and at a university hospital in 1972, discussions with residents at the bedside and in conferences focused on their feelings of frustration in attempting to provide sufficient care for patients, not on the cost of care or the ethics of rationing it.
By the early 1980s, residents were occasionally questioning the appropriateness of spending money on the intensive care of patients, especially elderly patients, with illnesses that seemed likely to be lethal.
By the late 1980s, such questions had become a daily staple at rounds in the medical intensive care unit. By that time, hospital administrators felt comfortable openly proposing the type of explicit rationing described in the case at the beginning of this article.
More remarkably, very few of the many medical students, residents, and staff members with whom I have discussed the case at conferences over the past few years have objected to the administrator's proposal or thought it unethical.
In my opinion, the proposal is morally flawed on two grounds. First, one must ask who -- what group of citizens or elected representatives -- gave the administrator the authority to ration medical care. Second, and more important, the administrator was proposing to withhold the better hip prosthesis from certain patients surreptitiously.
I see no objection to the proposal if the orthopedic surgeons were to tell their elderly patients that they practiced only at the particular hospital and were expected to use the less durable appliance. Patients who were unwilling to accept that prosthesis would be free to obtain care from surgeons who practiced at other hospitals that did not impose the restriction.
Such explicit information to prospective patients was not contemplated by either the administrator or the chief of orthopedic surgery, perhaps because it would have reduced the number of patients and hence income to both the orthopedists and the hospital.
Despite the increased emphasis on patients' autonomy and informed consent during the past two decades, very few physicians to whom I presented the case over the past several years thought that the surgeons were obligated to inform their elderly patients that they would receive the less durable hip prosthesis.
Society has the right to ration care, provided that the limitation of appropriate, effective care is openly revealed. One may question the wisdom of reducing necessary medical care before other means to contain medical costs have proved ineffective.
These means include greater efforts to encourage doctors to practice cost-effective medicine by reducing redundant and ineffective procedures, reductions in the excessive costs of administration and marketing, the imposition of appropriate controls on professional and hospital charges, and efforts to limit fraud and abuse.
Despite such measures, the costs of medical care may continue to increase at unacceptable rates, and our society may decide to ration care. It does not appear that we have reached that point yet.
Groups of patients and public officials have resisted most open efforts to ration care. Some health insurance plans that initially would not pay for some kinds of organ transplantation have changed their policy in response to public outcry.
There is public and political pressure to require health maintenance organizations (HMOs) and insurance companies to relax restrictions on the use of hospital emergency departments, referrals to specialists, and the length of hospital stays after normal deliveries.
It seems reasonable to conclude that, thus far, Americans are willing to pay the price necessary to avoid undisguised rationing of the medical care they receive. (As approval of the Oregon Medicaid plan shows, however, a majority of the public may be willing to accept rationing of medical care for the poor.)
If American society ultimately decides that rationing is a lesser evil than continued increases in the cost of medical care, physicians must take the lead in advising policy makers on the least damaging methods of rationing care and in clarifying the distinction between cost-effective practice and rationing. This advisory role should be distinguished from the responsibility of individual doctors to their patients.
The practitioner will continue to be responsible for providing the best care available within the limitations imposed by society. These dual but separate roles of doctors as advisors and practitioners were clearly described by Hiatt in 1975 and have been supported by others since then.
The key to the doctor's role as patient advocate is telling patients the truth. Without the uncompromising commitment of doctors to be honest with their patients about the reasons for offering or withholding specific medical care, patients may be deprived of the opportunity to seek other options.
For example, patients should be informed about very costly but somewhat effective therapy not offered by their HMOs, such as interferon for the treatment of multiple sclerosis. Without receiving such information from their doctors, patients cannot decide to appeal through the HMO's channels, pay for the treatment themselves, or form groups that try to influence health insurers or governments to change the rules.
It is easy to caricature the fundamental moral duty of doctors to tell their patients the reasons for the medical care they advise by carrying the requirement to an absurd extreme. It is not my view that physicians should obsessively explain the reasons for every routine, minor choice they make in caring for their patients.
But in the case of decisions that are likely to affect the health or even the survival of their patients, it is necessary to explain the reasons for selecting specific modes of diagnosis or therapy. The choice of a beta-blocker rather than a calcium-channel blocker or a diuretic for the management of hypertension does not require an elaborate explanation to the patient.
On the other hand, a doctor's failure to tell a patient with multiple sclerosis that interferon may be an effective treatment but that the patient's HMO does not pay for it is an ethical lapse.
Withholding the truth about rationing from patients has both practical and ethical consequences. It deprives patients of the right to contest the rationing of care for themselves and as social policy. Rationing care without explicitly informing patients also undermines the moral standing of individual physicians and of the medical profession. When the deception is revealed, it erodes patients' trust in their doctors.
Perhaps physicians should test their decisions by asking themselves whether the care they recommend to patients is what they would choose for themselves and their own families, and if not, why not. Unless and until society openly instructs doctors to ration the care they offer in their practices, physicians must continue to carry out their fiduciary duty to do the best they can for their patients and their moral duty to tell patients the truth.
[Norman G. Levinsky, M.D. is associated with Boston University Medical Center.]
