Professional obligations when patients pay out of pocket
Here’s what the ethics literature—and real-world experience—teaches us about helping patients make better cost-conscious choices.
First, and most coercively, doctors can simply refuse to treat a noncompliant patient. Except in emergencies, this is professionally and legally permissible; however, it is hardly ideal. When patients flatly cannot afford decent care, doctors often help by discounting fees or by arranging financial assistance.31
When patients are simply penurious rather than penniless, doctors can try arguing a patient into a wise choice. This tactic is not necessarily impermissible paternalism; it can be an act of respect and friendship. In our interviews, for instance, 1 doctor told a woman who balked at a mammogram that he was scheduling it anyway. Another called a taxi to drive a patient directly to the hospital out of concern that she might just go home. Yet another doctor enlisted family members in convincing recalcitrant patients. In sum, doctors dance a delicate dance to accommodate patients’ ambivalent wants and ambiguous needs.
Finding a new balance
You can accommodate the theory and policy of CDHC by acceding to a patient’s desire to pay less and get less.32 Professional obligations can be met by recommending the same care to each patient with a given condition, but informing patients of the costs and consequences of alternatives. Properly documented, these economically impartial conversations should protect physicians from malpractice liability. However, you need not go as far as having patients sign “Against Medical Advice” forms in order to continue seeing those who refuse optimal care. Doctors we interviewed thought it would be excessive to do this routinely and would threaten good relationships with their patients.
Unavoidably, solving consumerism’s problems will require conversations between you and your patients that take time—time that is already maddeningly limited. “Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall.”33 For preventive care alone, providing all recommended services “to a panel of 2500 patients could require up to 7½ hours a day of physician time.”34
Furthermore, some doctors may feel that expecting patients to pay more out of pocket is an unwise policy. That may be right; even well-intentioned social reforms sometimes make ill-conceived demands of professionals. But rightly or wrongly, our political economy, having resisted managed care (at the urging of doctors and patients), has accepted consumerism as another means to restrain unsustainable spending. In public policy forums, doctors may argue against government or market initiatives, but in clinical forums, there is a professional obligation to cooperate with prevailing social policy—especially when the policy forges the interests that patients bring to the examination room.
Acknowledgments
This work was supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research. The views expressed imply no endorsement by that foundation.
CORRESPONDENCE Mark A. Hall, JD, Wake Forest University, Division of Public Health Sciences, Medical Center Blvd., Winston-Salem, NC 27157-1063; hallma@wfu.edu
