Ask the Ethicist: Should your physician count costs?

Q: As a surgeon, I don’t know how much the things I use cost. It would be interesting to know the price of the medicine and equipment I use. What I don’t know is what the ethical concerns would be.

A: This question came up during an education day for surgical residents. “Mike” noted that with the growing shortage of pharmaceutical drugs in Ontario, he and his colleagues were researching the effectiveness and safety of alternative medications. In the process, the residents are discovering what the costs of various medications are, and finding that for little or no difference in effectiveness, they can often find significant cost savings. This led to the question – should physicians know the costs of the medicines and equipment they use? I would suggest to you that this measure would be good for hospitals, good for patients and bad for health care providers.

On one hand, there is a pretty solid body of literature that says involving front line staff in cost control is far superior to using top-down measures such as simply cutting budgets. It makes sense that if you give professionals responsibilities in controlling costs and reducing waste that they could be very effective at it. Doctors and nurses know best what is needed and what is wasted in terms of resources for patient care.

If we compared models of cost control in hospital care, it would seem that the staff who provide the care would be less likely to find savings where it hurt their patients. Administrators who lack facial interaction with patients in need tend to make business decisions – that makes sense if you never have to tell a patient that there’s no bed, no medicine, or an unconscionably long wait for care. This is the model wherein limitations on resources come from the top-down, and leave front-line staff with the task of rationing at the bedside. It seems infinitely more sensible to let the people who understand the needs have some level of decision-making as to what supplies should exist.

On the second hand, there is a concern about conflict of interest. A care provider who has an obligation to patients but also to the fiscal well-being of the facility could become overzealous and compromise patient care. Even in a case where the care providers choose the ‘next best’ drug as part of my treatment, the concern I have as a patient is exactly how far is one allowed to slip? How much of a drop in effectiveness and safety would be permitted and considered best possible care? It must also be said that patients might feel assured that resource allocation is determined in some part, by the staff they see and speak to. That might have a positive effect on patient trust and increasing patient trust offers many other benefits to patients.

On the third hand, even in the case of competent professional judgment, would care providers become concerned that any deviation from the safety of medications and equipment use abiding by the ‘standard of care’ could leave them in a vulnerable position? Hospital administration is already profoundly compromised by fears of litigation, and there is a culture of litigation fear amongst physicians. This fear is making it progressively harder to be a physician and there is research to say that it is causing them health problems. Is adding something like this to an already considerable workload just too much? I fear that would be the case, and savings accrued on the front end would be lost in the harm to the human resource side.