AMA, ACP ethics groups study distribution of health care

Discussions on the roles of physicians, insurers, employers and patients in making health care coverage and resource allocation decisions are part of a discussion which is charting the course of medicine as a profession, said Matthew Wynia, MD, director of the AMA Institute for Ethics.

Defining these roles and their ethical responsibilities is the subject of two high-profile papers produced by the AMA and the American College of Physicians. The AMA report was a project of its Ethical Force Program and is set to be published in an upcoming volume of the American Journal of Bioethics. The ACP's paper was produced by its Center for Ethics and Professionalism and appeared in the July 20 issue of the Annals of Internal Medicine.

"I think that the documents are part of an ongoing and evolutionary discussion about what it means to be a doctor and the physician's role in the society," said Dr. Wynia, who was a contributing author of the Ethical Force report. "We're seeing an increasingly frank discussion about dealing with these issues."

The AMA report, "Ensuring Fairness in Health Care Coverage Decisions," calls for the processes of designing and administering health benefits to be transparent, participatory, equitable and consistent, sensitive to value and compassionate.

The ACP report, "Ethics in Practice: Managed Care and the Changing Health Care Environment," is a statement of principles calling for respectful, truthful, fair and compassionate relationships; shared responsibility for stewardship of health care resources; fostering the ethical delivery of effective and efficient care; and informing patients about care and treatment options and the financial issues affecting the provision of care.

Confronting rationing

Although the discussion might become "increasingly frank," Dr. Wynia noted that both documents tended to avoid the word rationing.

"People don't want to use the word 'rationing' because it connotes purposely withholding services for economic decisions," he said. "Rationing does occur in the health care system. It's a matter of how -- some ways make sense and others don't."

Harvard Pilgrim Health Care Director of Ethics Programs James Sabin, MD, who worked on both papers, said the ACP paper did not set out to answer specific questions on rationing but to provide guidance and ethical principles that shape the way rationing questions are addressed.

"As I see it, the perspective of the group is right there in the first sentence: 'Health care resources are finite; their allocation requires hard choices,' " Dr. Sabin said. "That's not a shocking statement, but throughout the piece the perspective is given that this is not something for any one party to decide; it's for a democratic process to decide."

The paper also states, "Unaffordable care is inaccessible care," and the director of the ACP Center for Ethics and Professionalism, attorney Lois Snyder, said that gets to the heart of what the discussion is all about.

"The concern that animates all this work is access to care," Snyder said.

The ACP ethical principles come down against distorting facts to obtain benefits. They also call on physicians to inform patients about the rules of their insurance and any potential conflicts of interest or arrangements that could influence care.

Dr. Wynia said these papers represent a "laying down of a gauntlet" to physicians, saying that, even if they don't have all the answers, they need to lead the discussions about allocating resources fairly.

"If we ignore this, then someone else has to do it," he said. "If physicians don't take on the responsibility of resource allocations, it will fall to others."

The ACP project was led by Gail J. Povar, MD, a Maryland-based internist. Dr. Sabin said the fact that two medical organizations had two physician-led collaborative projects dealing with resource allocation was significant.

"This speaks to an advancement of the field, of moving beyond the black-and-white thinking of one stakeholder versus another," he said. "It's like an orchestra where we all have to play together to get the music we need."