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Should doctors聽think about聽cost when they鈥檙e helping you make your health care decisions?

Yesterday on the main KHN site we had a talking about the American College of Physicians鈥� latest update of its . The manual encourages doctors to be 鈥減arsimonious鈥� in doling out health care 鈥� that is, if you see our handy definition, 鈥渉aving an extreme reluctance to spend money.鈥�

The term, which has actually been part of the ethics manual since 1998, has recently been the source of controversy. Some say docs shouldn鈥檛 consider cost when caring for patients and call the idea聽鈥渞ationing鈥� 鈥� that minefield of a phrase 鈥� while others say doctors have an increasingly important role to help the U.S. control its health聽costs.

After we talked to experts for the round robin,聽I also sauntered around the Internet looking for blog posts on the subject. Here鈥檚 a sampling:

Aaron Carroll, at The Incidental Economist,聽in the : 鈥淚 think it鈥檚 fine for patients to see that some treatments may be a waste of money, and they might want to save that money. But I鈥檓 not sure that I think it鈥檚 as great an idea for doctors to consider 鈥渉ealth care resources鈥� in the same way. I鈥檓 just not as comfortable with that. At least, not when we鈥檙e talking 鈥渆thics.鈥� Is a physician who advocates for a treatment that鈥檚 not cost-effective acting unethically? Again, I don鈥檛 think that鈥檚 what the ACP intended鈥� (1/5).

Over at The Health Care Blog, Dr. Shilpa Iyer, in a crosspost from the blog, 聽about costs,聽by using a game:聽鈥淚 am not sure if and how practice patterns will or should change, but perhaps knowledge of the systemic charges will better inform our counseling of patients, and consideration of their resources. And, I did pause before obtaining an unneeded gonorrhea/Chlamydia culture the day afterwards with my newfound knowledge鈥� (1/3).

For the SHOTS blog, NPR鈥檚 Rob Stein , of the American Enterprise Institute: 鈥淔or Gottlieb, a parsimonious approach to medicine 鈥榬eally implies that care should be withheld. There鈥檚 no definition of parsimonious that I know of that doesn鈥檛 imply some kind of negative connotation in terms of being stingy about how you allocate something鈥欌�� (Stein, 1/3).

At his National Center For Policy Analysis blog, : 鈥淐an you imagine a lawyer discussing the prospects of launching a lawsuit without bringing up the matter of cost? 鈥β燨f course not.聽Then what is so special about medicine? Answer: the field has been completely corrupted by the idea that (a) patients should never be in a position to choose between health benefits and monetary cost, (b) doctors shouldn鈥檛 have to think about such tradeoffs either, (c) in order to insulate the patient from having to choose between health care and other uses of money, third-party payers should pay all the medical bills and (d) since no one else is going to think about what anything costs, the third-party payer is the only entity left to decide which services are worthwhile and which ones aren鈥檛鈥� (1/9).

At her ReformingHealth blog, Naomi Freundlich between the 鈥渧irture or vice鈥� of parsimony, in this cae: 鈥淚n the pursuit of a cure or in an attempt to extend a child鈥檚 life a doctor might feel that his patient is the exception, one of the few who has a chance of responding to a treatment not considered cost-effective in most others. This hardly seems a breach of ethics. But I also can see the wider intent of the ACP authors who state very clearly in the same highlighted box:聽 鈥淭he physician鈥檚 first and primary duty is to the patient.鈥� This is followed by, 鈥淧hysicians must base their counsel on the interests of the individual patient, regardless of the insurance or medical care delivery setting.鈥� Parsimony shouldn鈥檛 override a treatment decision that could benefit an individual patient.聽The real goal is to avoid wasteful, ineffective care that is not only costly, but likely to be harmful in the long run鈥� (1/9).