title: Cutting healthcare costs without rationing at the bedside: preserving the doctor-patient fiduciary relationship.
abstract: In his essay on bedside rationing, Peter Ubel argues that in an era of rising healthcare costs, it is time to relax the patient-centered ethic of physicians as unconditional patient advocates so they can individualize rationing decisions. This paper raises several concerns with the arguments and the examples he provides to make his case. First, he overlooks cost-effectiveness when making medical spending decisions. Second, his examples of wasteful, unproven and potentially harmful interventions call for physician education, not rationing, as he suggests. Third, informed patients can play a role in lowering costs through shared decision making. Fourth, individualized rationing decisions will worsen already pervasive disparities in medical care. The paper envisions the ideal cost-conscious physician as one who is knowledgeable about cost-effective practices, avoids unproven interventions whenever possible, and facilitates shared decision making through patient education. Such an individual would not, however, withhold interventions of proven benefit except when accommodating a patient's preferences for a particular therapy. The doctor and patient can only work together within the constraints of system-wide rationing if the fiduciary relationship is never violated.
authors.affiliation: Medicine and Pediatrics, College of Medicine, University of Illinois at Chicago, USA.
authors.forename: S J
authors.initials: SJ
authors.lastname: Lomas
authors.forename: C L
authors.initials: CL
authors.lastname: Rice
mesh_terms: D017046:Cost Savings; D003362:Cost-Benefit Analysis; D003657:Decision Making / Q000941:ethics; D026690:Ethics, Clinical; D020793:Gatekeeping / Q000191:economics / Q000941:ethics*; D017048:Health Care Costs; D015276:Health Care Rationing / Q000191:economics / Q000941:ethics*; D006801:Humans; D010358:Patient Participation; D010817:Physician-Patient Relations / Q000941:ethics*; D012959:Socioeconomic Factors; D014481:United States