Patient Autonomy, Health Care and Costs

Part of the ethical basis of our health care system is that patients have autonomy.

“The right of patients to make decisions about their medical care without their health care provider trying to influence the decision. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.”

Ideally, physicians provide information, explain alternatives, options and implications but the patient makes the decision. However, despite this, patients often make bad decisions. For example, patients with terminal illness with little or no chance of response or recovery may decide on the most aggressive, toxic, and costly treatment option. As a result, he/she may have more problems in their last days and the expenses for care in the last six months of life may exceed the all the expenditures for health care in that person’s life.

The physician’s influence should not be discounted. Most doctor’s explanations and recommendations are in the best interest of patients. However, physicians because of the nature of fee for service can have conflicts of interest that influence their behavior. The more they do, the more they make. Other factors such as the physician’s research interest, or financial interest in laboratory or imaging facilities may also affect decisions.

Pharmaceutical companies and other providers of health care technology influence patient decisions through promotional activities. Drug companies spend more on advertising than on research. Physicians are barraged with advertisements, “educational” opportunities and company propaganda. Lay people are deluged with media advertisements touting the benefits, with scant disclosure of toxicity and cost, of new drugs and technological advances. In many instances the new products are no better than older more cost effective agents. All of this is about influencing patient autonomy.

The cost of patient decisions is buffered by our system of insurance. With an insurance based system after paying the insurance premium someone else pays. Costs are under-represented in the care decisions. The patient wants to live a full and healthy life. The physician runs a business and like all businesses it has to generate enough money to pay expenses and salaries. Suppliers of services and health technology have the fiduciary responsibility to make a profit. Insurers, in addition to paying for care of their beneficiaries, also want to make money for their stockholders. Nowhere in our system is an objective balance to the universal incentive to spend more.

Our republican friends want a system that places greater financial responsibility on the patient. That would certainly increase patient concern about costs. But it would also eliminate most people from the health care system because the price for care would exceed the ability to pay. This creates the ethical dilemma of people with diseases who are unable to afford health care. Are we as a country willing to allow these sick people to die because of lack of access? At this point only very wealthy very insensitive people seem to favor this solution.

The question then is how to raise the level of cost consciousness in an insurance based system. A system that maintains the concept of patient autonomy but also provides efficient affordable services. The answer is not simple and will be part of the challenge that faces Secretary Daschle and the Obama administration.

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