The Oncologist’s Duty to Individual Patients vs Duty to Society

June 9, 2014

The issue of value in cancer care was a prominent theme at the 2014 ASCO Annual Meeting. A question that inevitably arises in any discussion of value is what the professional and ethical obligations of practicing oncologists are in the current climate of escalating healthcare costs.

The issue of value in cancer care-what it is and how to achieve it-was a prominent theme at the 2014 American Society of Clinical Oncology (ASCO) Annual Meeting. A question that inevitably arises in any discussion of value is what the professional and ethical obligations of practicing oncologists are in the current climate of escalating healthcare costs. To answer this question, ASCO invited two physicians to defend what might appear to be the two poles in thinking about the issues involved. In this debate, Daniel Sulmasy, MD, of the University of Chicago, argued the position that the oncologist’s priority should be to advocate for the good of the individual patient; Reshma Jagsi, MD, of the University of Michigan Health System, talked about the oncologist’s duty to society.

Dr. Sulmasy spoke eloquently about how bedside medicine has always been-and always will be-about individual patients. He quoted Aristotle (“The doctor does not treat humankind, but Caleus”) and Osler (“The practice of medicine is an art-not a trade…and not a business”) to make his point that financial incentives for bedside rationing require physicians to put aside their professional ethos and undermine trust by making the doctor an agent of the state or the market. He added that not only will any type of bedside rationing automatically result in injustice, but it is also unlikely to achieve the goals that its advocates claim it will achieve.

Yet, Dr. Sulmasy readily acknowledged that something needs to be done to rein in healthcare costs. Moreover, he believes that oncologists have a definite role to play in this “reining-in.” However, he proposed a strategy that would constitute a clear alternative to the growing tendency to treat medicine as a business and to reward physicians financially for using less costly treatments.

This alternate strategy would consist of two components. The first of these would be to strive to practice the art of medicine better and more rationally, aiming for what he termed “therapeutic parsimony” (using only enough therapy to make the patient well) and “diagnostic elegance” (ordering only those tests necessary to help the patient, resisting the impulse to satisfy physicians’ and patients’ technophilia). Both of these goals would be pursued purely in the interest of the patient; cost savings would inevitably result (through less use of treatments of questionable effectiveness and less ordering of unnecessary tests)-but these would be just a happy side effect.

The second component of the strategy that Dr. Sulmasy proposed was for oncologists to involve themselves in what he termed “engaged citizenship.” Everyone in the United States, he said, needs to engage in the difficult political conversation about how much healthcare the country can afford and how this should be distributed fairly. Physicians, as much as other citizens, should be involved in this conversation.

Yet, Dr. Sulmasy pointed out that in participating in the public discussion about how to curb healthcare costs, oncologists would still be free to practice in the interest of their patients; they would simply do so within the limits set by society.

Despite her purported role as the proponent of the “opposite” point of view, Dr. Jagsi actually espoused a position quite similar to that of Dr. Sulmasy. The difference in their two talks was largely one of emphasis, with Dr. Jagsi acknowledging upfront that the oncologist’s paramount moral duty is to his or her patients, but then going on to explore in greater detail and at more depth the role she feels oncologists can and should play in our national grappling with the problem of out-of-control healthcare costs. If oncologists focus exclusively on their duty to individual patients, she said, they are failing to uphold the full scope of their professional duties.

“Rationing happens,” she asserted. “The issue is, how does it happen?” Since resources are finite, allocation must occur. Dr. Jagsi argued that oncologists owe it to society to help ensure that rationing is accomplished as equitably and as wisely as possible. She noted that physicians’ specialized knowledge-which is almost always acquired at least in part through public funding-gives them a professional duty to participate in a prominent way in the national effort to rein in healthcare spending. “We are in such a privileged role,” she said, “we should be leading the charge.”

She enumerated a number of ways in which oncologists can exercise their stewardship of our healthcare resources. They can call attention to obvious instances of waste and work to eliminate them. They can work to develop a robust evidence base for what constitutes true value in cancer care, and can take a leadership role in the public deliberation over priorities in healthcare. In addition, she noted, while we may not want to incentivize cost savings, we also want to make sure not to disincentivize it either.

Thus in the end, this “debate” between a defender of the oncologist’s duty to his or her individual patients and a proponent of the oncologist’s duty to society actually set forth a clear path toward the goal of true value in cancer care. Moreover, it is a “high road” that respects physicians’ time-honored obligation to patients, while at the same time sets forth concrete ways in which they can make real and valuable contributions to the national effort to rein in healthcare costs.