An article by Dr. Jon C. Tilburt, "Why the Ethics of Parsimonious Medicine Is Not the Ethics of Rationing" was recently presented to our hospital’s palliative care committee. This certainly has implications for our care of cancer patients when it comes to frequency of expensive diagnostics, chemotherapy, and bone marrow transplantation.
Rationing can be described as explicit or implicit withholding -- and allocation -- of beneficial resources for certain patients. Situations may include organ transplantation, distribution of blood products, or mass casualty events. In these circumstances, pre-specified principles guide how the resource is delivered for maximum benefit.
Care in our current healthcare system is rationed by the ability of the patient to pay: The uninsured are much more likely to do without needed medical care. They are less likely to see a doctor within a given year, have fewer visits annually, and are less likely to have a regular source of medical care. Uninsured persons receive fewer preventive services and less care for chronic conditions than the insured.¹
In the American College of Physicians's sixth edition of its Physician’s Ethics Manual, it included the statement that doctors should practice “parsimoniously.” When I first heard this term, I was uncertain of its meaning as I had never heard it referenced to medical care before.
According to Dr. Tilbert, parsimonious means delivering appropriate healthcare that fits the needs and circumstances of patients, and actively avoids wasteful care. Parsimonious care is identified as:
- Starting with basic, proven tests and treatments.
- Calibrating intensity of testing and treatments that are consistent with the seriousness of the illness and patient’s goals.
- Using good clinical judgment by asking, “Will this test change the disease management?”
- Using time as an ally -- one of our physicians refers to this as “tincture of time.”
- Tolerating uncertainty.
- Using interpersonal skills to allay patient fears.
Parsimonious care leaves the option for our cancer patients to use investigational, expensive drugs -- but only when other, more established options are exhausted, and when they are consistent with the patient’s personal and clinical circumstance.
Parsimonious medicine reflects a commitment to “do no harm,” and to help even when the sick cannot be cured. When it comes to our cancer patients, care for each individual patient is prioritized, the best care is administered, and harm is minimized. Care is based on the ethical principles of beneficence and nonmaleficence. This type of medicine requires the use of judgment and the virtue of prudence.
Elimination of the use of ineffective and inappropriate services can result in major cost savings. Parsimonious care is not withholding something effective in order to provide to someone else. Instead, it limits the use of unnecessary and potentially harmful services.
In your clinical experience, do you see diagnostic testing, treatments, and protocols utilized from evidence-based practices? Clearly, patient care must be based on individual patient needs combined with sound judgment.
What are your thoughts on this issue? Can effective healthcare be good healthcare, both economically and medically?
- Institute of Medicine (IOM), (2001). “Coverage matters: Insurance and Health Care” Washington DC: National Academies Press.