Just Caring: Parsimonious Care in Certain Uncertain Circumstances

Leonard M. Fleck, Michigan State University


Uncertainty is a Hydra-headed phenomenon in health care. From a physician’s perspective there often is uncertainty (many degrees) with respect to diagnosis (and the reliability of the technologies needed to establish a diagnosis), prognosis (and the infinite variety of genetic, physiological, pharmacological, behavioral, technological, economic, and cultural factors that affect the outcome of prognostic judgments), the appropriateness of a therapeutic intervention (perhaps related to medical disagreement), the likely effectiveness of a therapeutic intervention, the risk/ benefit ratio of a therapeutic intervention (potentially complicated by co-morbid conditions), the likelihood of a patient complying with the behaviors needed to maximize the likelihood of a therapeutic outcome, the applicability of a clinical guideline to this patient in the clinic, the reliability of the evidence and research behind that guideline, and, finally, the sheer randomness of natural events at various levels in the health care encounter. That is the background for this presentation.

Our question, however, is this: How should all this uncertainty be addressed in the economic/ political context of having to do health care rationing, and in the ethical context of having to do that rationing justly? Today there is an increasing emphasis on the obligation of physicians to provide parsimonious care, i.e., the prudent and cost-effective use of health care resources in caring for individual patients. To focus discussion I offer several common examples, such as $100,000 precision cancer drugs, $40,000 implantable cardiac defibrillators, PCSK9s for lowering “bad” cholesterol, access to ICU beds---- all of which represent uncertain benefit at very great cost. DRGs as a hospital payment mechanism are part of the same problem since they can motivate “premature” discharge of a patient, thereby putting them at uncertain risk for an otherwise avoidable bad health outcome. If physicians cooperate with the intent of DRGs (or other care protocols intended to promote parsimonious care), are they treating their patients unjustly? Must physicians be virtually certain that no harm will come to their patients in order to be just and justified in carrying out parsimonious protocols? “No” is the response I will defend. If a patient does not have a just claim to some health care resource, then the harm that “might” befall them as a result of that denial is properly regarded as being unfortunate but not unjust.

Access to health care resources is about access to a limited common good. This is what makes such access a matter of justice rather than a matter of informed consent wherein a patient weighs from their point of view the risks and benefits (and related uncertainty) they are willing to trade off. Matters of justice require social decisions. Patients do not have a presumptive just claim to a $100,000 cancer drug if there is only a small chance that drug would yield an extra six months of life. What level of certainty would generate such a just claim? There is no objectively correct answer to that question. It needs to be resolved, I will argue, through a process of rational democratic deliberation, the results of which will be just and legitimate for all in the relevant clinical circumstances.