Author: Let The National Debate On 'Parsimonious Medicine' Begin

Uh oh. I just looked up the official definition of "parsimonious" and found, "characterized by or showing parsimony; frugal or stingy." Receiving "frugal" medical care would be just fine with me."Stingy," not so much.

My dictionary-diving was prompted by the controversial new ethics guidelines just put out by the American College of Physicians, the country's second-largest medical group. As NPR reported, the new guidelines include this language:

Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available."

I asked Georgetown University's double-threat doctor-lawyer, M. Gregg Bloche, for his take on the new guidelines and their implications. He's the author of the book, "The Hippocratic Myth: Why Doctors Have to Ration Care, Practice Politics, and Compromise their Promise to Heal." He replied by email:

The new ACP ethics guidelines on the place of cost in clinical judgment take a step forward by affirming that costs ought to count. But the guidelines fail to explain how costs should count. This failure is likely to beget confusion, unfairness, and distrust.

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'The ACP’s murkiness on the matter of whether and how to balance benefits against costs sets the stage for case-by-case, subjective judgment about the value of people’s lives and well-being.'

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The guidelines call upon physicians to “practice effective and efficient health care” and to provide “[p]arsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient.” That care should be “effective” is a clear-cut proposition. Treatment that’s futile in the sense that it stands no chance of making a positive therapeutic difference shouldn’t be provided. This ought to be a no-brainer. Regrettably, it’s often honored in the breach. So the ACP has done a service by reminding its members of this bit of ethical common sense.

The ACP’s call for doctors to practice “efficient” and “parsimonious” care is another matter.

Efficiency, as economists and policy wonks understand the term, entails the weighing of benefits against costs – a sharp break with the Hippocratic ideal of undivided loyalty to patients. But the ACP says nothing about how benefits should be counted and balanced against cost; nor does it speak to how such balancing might be squared with Hippocratic commitment. The term “parsimonious” adds to the trouble. It’s a low-resolution word that leaves space for physicians to make their own subjective judgments about the benefits that should be forgone to conserve shared resources.

To be sure, the ACP purports to define “parsimonious” care: it’s care that “utilizes the most efficient means to effectively” diagnose and treat. But this definition elides medicine’s largest cost-control challenge: different tests and treatments (costing more or less money) yield different levels of effectiveness. Is it the ACP’s position that doctors should choose only from among those tests and treatments that yield maximal effectiveness (within current scientific limits)? Or is the ACP signaling to its members that effectiveness can and should be compromised to control costs?

The ACP’s murkiness on the matter of whether and how to balance benefits against costs sets the stage for case-by-case, subjective judgment about the value of people’s lives and well-being. Such judgment belies American ideals of procedural and substantive fairness. Beyond that, it leaves wide berth for clinical practice variation tied to personal wealth, insurance status, and social standing.

The guidelines’ authors deserve credit for inviting conversation about the inevitable: doctors will need to balance costs against benefits, or our country’s medical bills will bring about our fiscal ruin. Indeed, as I’ve written elsewhere, doctors already do so, without admitting it. What’s urgently needed now is a national conversation about how to do so, in keeping with doctors’ Hippocratic commitment and with American ideals of decency.