In Practicing Medicine, Is Parsimony a Virtue or Vice?

The American College of Physicians recently released a new version of its thoughtful ethics manual, a 37-page document published in the Annals of Internal Medicine that provides guidance for its membership of 132,000 internists on issues as varied as whether doctors should participate in torture (they absolutely should not), use social media (carefully) and provide uncompensated care to the poor (yes, an unspecified “fair share’).

But despite the breadth of this publication and its ambitious attempt to guide the ethical practice of medicine, much attention has been focused on a single highlighted text box that urges doctors to actively confront the current crisis in health care by considering cost-effectiveness when providing care. The controversial box states the following:

“Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely and to help ensure that resources are equitably available.”

The manual instructs doctors to choose procedures and treatments that are backed up by “the best available evidence in the biomedical literature, including data on the cost effectiveness of different clinical approaches.”

To some doctors and medical ethicists this recommendation to practice “effective and efficient health care” and to be cognizant of limited resources is a bold and timely move by the ACP. Ezekiel Emanuel, a bioethicist at the University of Pennsylvania and one of the architects of Obama’s health care policy, writes in an accompanying editorial in the same issue of the Annals;

“Here is a professional society unafraid of advocating the principle of cost-effectiveness. These positions on efficiency, parsimony, and cost effectiveness constitute an important shift, if not in ethics then in emphasis.”

Emanuel adds that the challenge is for this philosophy to move into the routine practice of medicine, “so that the sign of a good physician is not the one who delineates and chases every possible ‘zebra’ in the differential diagnosis, raising costs with no concern.”

To others, using the word “parsimonious” in the same context as providing medical care has troubling connotations; reigniting a long-simmering debate over rationing.

Aaron Carroll, an associate professor of pediatrics at Indiana University’s School of Medicine and blogger at The Incidental Economist, has long championed considering cost-effectiveness in health care; “This means saying no to some treatments and tests, because we have to use health care resources responsibly,” he writes in a recent post about the ACP ethics manual. But he wonders if using the word “parsimonious,” “meaning ‘extreme unwillingness to expend resources’ or ‘frugal to the point of stinginess’” was a wise choice for such a venerable publication. (If we’re using these common definitions, I would tend to agree; after all, frugal care sounds like a good idea; but isn’t stinginess a vice?) Carroll asks, does this imply that “a physician who advocates for a treatment that’s not cost-effective [is] acting unethically?”

Carroll adds that there is an incongruity between asking a physician to consider limited health care resources at the same time that he or she is frantically trying to save a patient’s life, for example. “Asking them to divorce themselves from the very human feelings that compel them to do anything that might help their patients is not something that I think will necessarily improve the practice of medicine. They also should be human.”

I understand what Carroll, as a clinician means. In the pursuit of a cure or in an attempt to extend a child’s life a doctor might feel that his patient is the exception, one of the few who has a chance of responding to a treatment not considered cost-effective in most others. This hardly seems a breach of ethics. But I also can see the wider intent of the ACP authors who state very clearly in the same highlighted box:  “The physician’s first and primary duty is to the patient.” This is followed by, “Physicians must base their counsel on the interests of the individual patient, regardless of the insurance or medical care delivery setting.” Parsimony shouldn’t override a treatment decision that could benefit an individual patient.

The real goal is to avoid wasteful, ineffective care that is not only costly, but likely to be harmful in the long run. It brings to mind a sad story a friend told me just this morning about the last months of her father’s life. His health had deteriorated after suffering a stroke and heart attack seven years before, and the 75-year-old had heart failure, kidney failure and a host of other problems. Doctors recommended bypass surgery, telling family members that the procedure had a 95% rate of success and usually required only a short recovery time. Instead, when they opened the man’s chest, they realized his arteries were too compromised and his heart valves too leaky to do the bypass surgery; instead they did a little artery cleaning and sewed him back up. As his condition got worse, the doctors promised he could be a candidate for a valve replacement if he just got stronger. He would still have to live in a nursing home and have dialysis three times a week at best, but he would be alive, they said.

For the next month, my friend’s father stayed in the hospital, taking a slew of drugs to keep his kidneys functioning while also slowing the build-up of excess fluid caused by heart failure. When he finally went into cardiac arrest, the doctors (on the urging of the his wife) ignored his DNR and put him on a ventilator. The second time it happened, he died—having spent the last two months hospitalized, undergoing open-heart surgery and kept alive by machines. Parsimonious care in this case would surely have been the more humane, ethical care—saving both suffering and enormous health care costs.

It is in this vein that Virginia Hood, president of the ACP defends the use of “parsimonious” in the ethics manual, telling NPR’s Rob Stein, “Every time you prescribe something for a patient or subject them to some kind of investigation there’s a risk of harm,” she said in a telephone interview. “So the concept of doing less is actually a really good concept, not a negative concept.”

As to the word itself; “the college simply means that efficient health care is good health care — both economically and medically. Parsimonious is a good word in the sense that it means that you use only what’s necessary,” said Hood. “I don’t see a particular problems with that. Maybe it has some connotations where people think frugality or being parsimonious is the same as being mean or inadequate. But I don’t think that is the real meaning of that word.”

Hood’s definition of parsimony may be a bit off and using a different word in the manual—like frugal, or conservative or prudent—would likely have avoided the debate over semantics. But the truth is that cost-effectiveness is an ethical consideration in health care. Rationing, skimping and stinginess already exist in our current health care system—high deductibles, unaffordable insurance premiums, poor access to specialists for Medicaid patients, 15-minute psychiatric visits for the mentally ill…the list goes on. If the ACP is asking doctors to instead consider a more effective, efficient and equitable use of a limited resource, what could be wrong with that?