title: How Should Therapeutic Decisions about Expensive Drugs Be Made in Imperfect Environments?
abstract: Clinicians must inevitably make therapeutic decisions under nonideal conditions. They practice in circumstances that involve incomplete evidence. They deliver care in health care systems that are complex and poorly coordinated. Each of the patients that they take care of is unique while research offers evidence regarding relatively homogeneous populations of patients. Under these circumstances, many parties-medical scientists, reviewing agencies, insurers, and accountable care organizations-can and should contribute to optimizing the development, approval, funding, and prescription of therapies-particularly expensive and marginally beneficial therapies. In aggregate, they should aspire to achieve a pattern of fair, cost-effective therapeutic decisions to ensure a sustainable health care system. Here we offer some suggestions regarding decisions that physicians might pursue to facilitate fair and cost-effective patient care.
authors.affiliation: Professor of philosophy and medical ethics in the Center for Ethics and Humanities in the Life Sciences in the College of Human Medicine at Michigan State University in East Lansing, Michigan, and the author of Just Caring: Health Care Rationing and Democratic Deliberation (Oxford University Press, 2009).
authors.forename: Leonard M
authors.initials: LM
authors.lastname: Fleck
authors.affiliation: Head of the Section on Ethics and Health Policy in the Department of Bioethics at the National Institutes of Health (NIH) in Bethesda, Maryland, and chief of the ethics consultation service at the NIH Clinical Center.
authors.forename: Marion
authors.initials: M
authors.lastname: Danis
mesh_terms: D060866:Accountable Care Organizations; D003363:Cost Control; D003362:Cost-Benefit Analysis; D003657:Decision Making / Q000941:ethics*; D003695:Delivery of Health Care / Q000191:economics / Q000941:ethics*; D016527:Drug Costs; D011307:Drug Prescriptions / Q000191:economics; D026690:Ethics, Clinical; D006801:Humans; D010820:Physicians; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000941:ethics*; D012935:Social Justice