Patients face real risks with "defensive" medicine
Patients face real risks with "defensive" medicine
It's often left out of ethical debates
Careful stewardship of scarce resources remains an ethical obligation of physicians, but avoiding harm to patients is a higher priority, argues Howard Brody, MD, PhD, John P. McGovern Centennial Chair in Family Medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston.
Brody says it is not generally appreciated that defensive medicine "is virtually, by definition, unprofessional." Defensive medicine is generally defined as a test or procedure that the physician does not think is indicated, but is done solely to ward off a hypothetical lawsuit possibility, he notes.
Professionalism requires that the physician do what's best for the patient, not what's best for the doctor, says Brody, and avoiding a lawsuit is clearly putting the physician's self-interest ahead of the interests of the patient.
"That said, it is very sad that good physicians spend so much time and energy worried about lawsuits under the current system," he says. "Everyone would be better off if there were meaningful changes in the current tort system."
Brody says the fact that important consumer groups, including Consumer Reports and AARP, are on board with Choosing Wisely and that the media coverage when the initiative was rolled out in April 2012 was largely positive, are a signal of progress.
"They are not saying these tests and procedures should not be done, or not paid for by insurers," he says. "Rather, they say that before these are done, physicians and patients should have a serious conversation about the pros and cons."
Ethical justification
Discussions about cost containment typically revolve around "rationing," and assume that saving money for society is the only ethical justification, as opposed to a far more important ethical justification, says Brody, referring to the adage "primum non nocere."
"A test or procedure that cannot provide any patient benefit according to our best evidence can still cause harm," says Brody.
There is no possible justification for exposing patients to that risk of harm if the physician sees no benefit to a test, he argues — at least not unless the patient is fully informed of the risks and chooses to accept them.
"It is very hard to find ethical objections to shared decision-making, which ought to be done routinely in medicine anyway," says Brody.
Careful stewardship of scarce resources remains an ethical obligation of physicians, but avoiding harm to patients is a higher priority, argues Howard Brody, MD, PhD, John P. McGovern Centennial Chair in Family Medicine and director of the Institute for the Medical Humanities at the University of Texas Medical Branch in Galveston.Subscribe Now for Access
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