Debating the Oncologist's Role in Defining the Value of Cancer Care: Our Duty Is to Our Patients

Health care spending in the United States is at crisis levels, costing $2.7 trillion in 2011 and comprising 18% of the gross domestic product. Cancer therapy constitutes approximately 5% to 11% of the total health budget and is the most rapidly growing segment of medical expenditure. Debate about the best ways to curb the costs of cancer care has put the practicing oncologist in the front lines. Insurance claims data reveal that anticancer drugs and technology account for most of the cost of cancer care. Oncologists must choose the right treatment options for their patients but must weigh the value of each therapy without compromising the patient-physician relationship. Oncologists are increasingly struggling with the ethical dilemma of weighing their duty to their individual patients against their duty to society at large. Although we believe that oncologists have social duties and play a vital role in helping to control the costs of care, we argue that within the context of the health care cost debate, the primary duty of oncologists is to their individual patients. We vigorously object to the notion that cost containment is best accomplished at the bedside. In practicing clinical medicine, we are not practicing public policy or economics. Bedside medicine is about individual patients and not about populations. In practicing bedside medicine, oncologists have long recognized that medicine is an art as well as a science. In the science of medicine, we are concerned with populations, not individual persons. We ask questions based on the best available medical evidence and generalize results to the broad population of patients with all cancers. By contrast, in the art of medicine, we are concerned with individuals. Knowing the science, we ask ourselves the fundamentally moral question of what we ought to do for our individual patients. This involves science but it is directed toward an individual. We take account of the totality of the circumstances of the patient, his or her comorbidities, prior response to treatment, tolerance for adverse effects, and values and preferences. For example, knowing that lapatinib plus capecitabine can improve progression-free survival in advanced human epidermal growth factor receptor 2/neu–amplified breast cancer but can cause significant diarrhea, we ask, Should I prescribe lapatinib plus capecitabine for this patient? Therefore, the art of medicine is the application of our scientific knowledge to the care of individual patients. As Aristotle wisely observed, the doctor does not treat humankind in general, but an individual who is sick. Thus, the goal of the encounter between a doctor and a patient is for the good of the individual patient. This goal is limited by the state of the science of medicine and by the availability of resources. For example, expensive therapies such as pertuzumab or crizotinib are unlikely to be available to an oncologist practicing in rural Somalia. But within the constraints of these parameters, patients need to be able to trust that their physicians are acting for their individual good and making wise use of the available resources. Some people argue that medicine is just a business and that we should get over our romantic notions and accept that this has always been true. Physicians and ethicists have insisted for millennia that medicine is not a market commodity. Hippocrates wrote that “Any wisdom, in fact, wherein works some scientific method, is honorable if it be not tainted with base love of gain and unseemliness.” In the 20th century, Sir William Osler wrote, “The practice of medicine is an art, not a trade; a calling, not a business.” In fact, medicine does not fit standard market assumptions because of the significant externalities, lack of fungibility, and relative price inelasticity. Given the necessity of health for access to so many other goods, many economists have suggested that medicine is better thought of as a public good. None of us “own” health care and its knowledge base. Moreover, the existential situation of sickness demands that patients be able to trust that their doctors are applying this public good for their individual benefit, not the physician’s personal financial benefit or the good of society at large. Practicing medicine is different from selling shoes. None of us will wake up tomorrow suddenly in need of $100,000 worth of shoes. Any of us could wake up tomorrow suddenly in need of $100,000 worth of health care. The true value of health care is not measured in dollars but in the priceless dignity of the persons medicine serves. Oncologists must face the fact, however, that rising health care costs now threaten to crowd out other social goods. One of the great questions we face is how to control health care costs without undermining the professional ethic on which individual patients must rely. We argue that calls for physicians to engage in bedside rationing are misguided, and that the associated moral conflicts are made even worse when third parties offer bonuses for cost-effective care or penalties to practitioners (or to groups of practitioners) depending on how much money they use in caring for the sick. There are several reasons why this is morally problematic. First, financial incentives for bedside rationing threaten the integrity of medicine, which requires that physicians put aside at least some of their self-interest for the sake of their patients. Second, financial incentives for bedside rationing JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 32 NUMBER 36 DECEMBER 2