March 28, 2013 | Posted By Paul Burcher, MD, PhD

Two articles in the New York Times raise a disturbing question regarding the ethics of cancer treatment in this country.  The first on ovarian cancer treatment noted that despite significantly better survival data with intraperitoneal chemotherapy (IP) over intravenous chemotherapy (IV) for ovarian cancer, most oncologists were still using IV chemotherapy. The reason given is that IP chemotherapy is more difficult to give, and more labor intensive, but is not reimbursed at a higher rate.  That is, physicians are routinely withholding the more effective treatment for economic reasons.  Another recent article describes how oncologists tend to choose more expensive chemotherapy even when it is not more effective because they are paid a percentage of the drug’s cost. 

It is an often-repeated truism that physician behavior will follow economic incentives perfectly—if you wish to reduce physician procedures capitate patient care, if you wish to increase patient procedures, pay physicians on a fee-for-service basis.  While this has been empirically demonstrated, it is a bit hard to accept that this adage remains true even when physicians seems to be crossing the line into unethical behavior in order to follow the almighty dollar.  The IP chemotherapy issue is most troubling because it represents physicians giving care they know to be inferior because the better treatment costs more to deliver, and this reduces their own income.

At this point it remains unclear how the Affordable Care Act will over time change physician compensation, but it has been clear for some time that the current fee-for-service model is flawed, and needs major revision.  However, many (myself included) believed that despite the fact that physicians change their practice patterns somewhat based upon economic incentives, they would still be bound to provide the best possible care by the ethical duties of the profession..  That is, that their behavior would remain within ethical bounds determined by their professional integrity.  Both of these recent articles suggest that this presumption is naïve, but what are the possible solutions?  We could figure out a way of paying physicians that removes all economic incentives that might be potentially be harmful to excellent patient care—but what would this look like?  It may represent employed, salaried physicians, but there may be a loss of productivity associated with this, and it is certainly not a solution supported by physicians.

Perhaps, since we are analyzing this as an ethical problem in physician behavior we should also see the solution as an ethical one as well. Have we failed to teach the ethical basis of medicine to our medical students, or have they forgotten that the basis of medicine is a relationship founded in trust, not market economics? I suspect many of the physicians whose ethics I am deeming suspect did learn medical ethics in medical school, but have ignored these teachings because they are no longer in academic environments where ethicists are more prevalent.  Medical practices need to be run as businesses, but physicians need to be reminded that they are members of a profession, professors of an oath, and that oath is a promise to care for patients more than balance sheets. Do we need ethics CME (continuing medical education) as a way of reminding practicing physicians that our duty to patient care can never be superseded by the desire to maximize profits?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

3 comments | Topics: Clinical Ethics , Ethics and Morality , Oncology , Patient Care , Research Integrity


John Seo

John Seo wrote on 03/29/13 10:31 PM

It’s a sad fact though we couldn't blame the physicians if they are looking after on their income first than taking care of their patients because we all know that they have their needs too. It’s a good suggestion to let them undergo a continuing medical education so that they’ll be reminded always to assure the safety first of the patients .Moreover, maybe we can tap the governments too if they can do something about this that would resolve the issue.
Trevor Ray Slone

Trevor Ray Slone wrote on 04/07/13 9:27 PM

Great article Paul. I do think that such CME regarding ethics is needed, but we cannot be so naive still to think that even with such training, unless there is some sort of daily, weekly, or monthly legal/formal ethical accountability involved, that this sort of thing would not continue. I realize that modern secular humanism has popularized the idea that humans are by nature good, and to be sure we would all like to believe that, but the bottom line is that deep down we all know that humanity is corrupt at its core, for ego and self-preservation are unequivocally our number one priority, unless of course we have some reason for thinking, believing, and acting otherwise. That reason for seeing things in a different light is almost always religious of some sort, but the fact is that unless people start caring more about others than they do about themselves, this sort of blatant disregard for the well-being of others is not likely to go away, no matter how much continuing education is provided.
The Coeus

The Coeus wrote on 04/24/13 2:36 AM

Great article. This is true, ethics CME is needed to all physicians. We cannot point out them in this case. But regularly conducting practices and holding exams to them, they may become more perfect.

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