Ethics and Evidence-Based Medicine: Is There a Conflict?

Erich H. Loewy, MD

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In This Article

Providing Elbowroom

Physicians who must defend why they deviated from EBM in a particular case are left with lesser amounts of elbowroom in decision-making. They are limited in what they can order when it comes to laboratory work, x-rays, consultations, or medications. Physicians -- who are held liable for not doing something -- are faced with MCOs questioning why it is that they want to do something. In many states MCOs under the Employee Retirement Income Security Act (ERISA) cannot be sued -- physicians can. I would claim that the secretary who has refused my physician permission for an MRI or insisted that 20 mg rather than 40 mg of a certain medication will be sufficient is engaged in the practice of medicine without a license. Overwhelmingly, healthcare management organizations (HMOs) and MCOs love EBM -- not so much because it will improve patient care but because it will increase the profit margin of the stockholders. Let us be honest: The primary interest of MCOs, insurance companies, and similar institutions is not the patient's good (except when it becomes obviously bad enough that it is no longer competitive) but making as much profit as possible. Physicians, on the other hand, if they are to be true to their oath, are interested in the patient's good even if that good is expensive.

There are, then, several differing interests involved:

 

  1. The physician's interest is above all, hopefully, the good of the patient and not the profit of the company. (Nevertheless, when faced with incessant and often changing MCO requirements based on the abstract use of EBM, it is not difficult, as mentioned above, to cave in and accept "the system" as the norm.)

  2. The employer is interested in saving as much cost as possible in buying a given healthcare plan for its employees.

  3. The patient is interested in the best "quality" of medical care available. This by no means implies that the more something costs, the better it is. But the opposite is equally and more frequently the case.

The reason most of us go to a physician, other than to have a slip signed, is because we are ill, vulnerable, and, often, in pain. At such times many of us will hope that the physician will advise us with our interest in mind. Our autonomy is distorted and often we do not wish to participate in making decisions. We hope that our physicians will not advise or treat us on the basis of MCO restrictions but because they feel that what is advised is medically indicated. Patients in general want their physicians to have enough elbowroom from their MCO or HMO, even though that is shrinking daily.

A physician who knows of an effective treatment given often and with relatively good results, but who withholds or downplays this information from the patient because the MCO finds that providing this service, while it may save a life, decreases the income of the stockholder, is acting unethically. For millennia, patients have assumed that physicians will act on their behalf and set other considerations aside. Expectations do not create duties. But whenever an expectation is held by one and in general is faithfully executed by the other (especially when this has happened over millennia), an obligation to do so -- or to inform the public otherwise -- is not unreasonable. This age-old assumption, to our everlasting shame, may be changing: Patients are beginning (for diverse and often justifiable reasons) to have less and less trust in the medical profession as a whole and in their physician in particular.[9,10]

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