Health economist, Professor Gavin Mooney, writes:
The AMA recently came out in criticism of the government’s plans on the proposed membership of Lead Clinician Groups. It is fair enough that Dr Andrew Pesce, the AMA President, sticks up for his membership on that front. Here I do not want to get into a debate about turf wars between different clinical groups.
Where I do get concerned, however, is when Dr Pesce gets into questions around the roles for clinical doctors with respect to efficiency and equity. He states: ‘Specifically, doctors should be involved in decision-making about funding for infrastructure, staffing and training within their hospital to ensure it is allocated efficiently and equitably.’
It is an issue that was returned to by Adam Cresswell recently in the Weekend Australian.
But before getting into the question of the rights and wrongs of doctor involvement in issues of efficiency and equity, let me muse on defining these terms – and perhaps challenge Dr Pesce also to muse on them.
To me, as an economist, efficiency is about value for money. Is this use of scarce resources on this group of patients in this hospital better than using the resources on this other group of patients in the hospital? If it is, then it is “more efficient”.
Of course there are value judgments involved in judging “better”. Answering the question of whether within a hospital $X is better spent on 5 heart transplants (largely length of life health improvements) or 100 hip replacements (largely quality of life improvements) cannot be done without using value judgments. Certainly these also involve judgments about medical effectiveness and clinicians’ technical judgments are needed on such effectiveness.
Beyond that, the value judgements in weighing up the benefits of these different options are not for clinicians. The question becomes: after we hear from the doctors about the health improvements from these two options – in other words their effectiveness – which of the two provides the greater benefits, which is better?
This judgment, this value judgment, is not for doctors to make. It is a social value judgment.
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Equity is about fairness. But it is a social concern and in the end just how to define fairness has to rest with society at large. It might be seen in terms, for example, of equal access for equal need or of equal health. It might incorporate simply treating equals equally or it might have concerns for positive discrimination.
Now how many medical clinicians are trained in such matters? Some public health doctors are – but hospital clinicians? No. These clinicians can advise on the effectiveness of care – how much health improvement will be delivered – and I would defend to the death their right to do so.
But efficiency? No.
Equity? Again not clinicians’ territory. Certainly the policy on the equitable use of hospital resources is something that clinicians will have to be involved in implementing. Defining and designing what is meant by equity? No.
There are three issues here. First there is the question of competence. Medical clinicians are not trained in such matters. Secondly there is the question of what might best be termed “social legitimacy”. The values medical clinicians bring to judgments about efficiency and equity are only relevant in so far as they reflect the values of the community. (They might – but why not go to the community directly?)
Thirdly, and in some ways most worrying to me as a potential patient (and I would guess most worrying to Dr Pesce), is the ethical issue. When I am seeing Dr Chua about (say) my prostate, I want Dr Chua to be concerned only about me (although I accept that he or she will have a concern for the patients whom he or she might be keeping waiting). In economics jargon Dr Chua can rightly (I believe) be left to judge the “opportunity cost” – the benefit foregone – in treating me as compared with treating his or her other patients.
What I do not want is for Dr Chua to be asked to form judgments about the relative values of treating my prostate versus Fernando Smith’s melanoma or Jeannie Artells’ psychosis. There is or I believe ought to be a limit on how widely a medical clinician – indeed any clinician – should be asked to see and interpret “opportunity cost”.
It is in my view simply not fair to ask a clinician to be an advocate not only for their patients but also for society or even the hospital as a whole. It is not fair on them and it is not fair on their patients.
Yet asking medical clinicians – as Dr Pesce seemingly wants – to be involved in advising not just on effectiveness of care but ‘efficient and equitable use of hospital resources’ is, I would submit, putting them in this ethically invidious and untenable position.
I’d prefer not to do that, and I’d prefer that when my doc is treating me, he or she has to worry only about his or her patients (including me!), and not also about society’s resource use – and that he or she sticks to what he or she is trained to do.