Open letter to the CPSA on Professional Courtesy

The College of Physicians and Surgeons of Alberta has released Advice to the Profession on Professional Courtesy, following up on the recommendations of the Vertes Report. You can find it here: http://www.cpsa.ca/wp-content/uploads/2017/01/AP_Professional-Courtesy.pdf?x91570

I’ve written the College an open letter (Open Letter to CPSA Professional Courtesy Advice), because they seem to imply that my report to the Vertes Inquiry was influential on their advice. I don’t really see that my views had any influence on them at all. Perhaps they worked with the idea of “conflict of interest” from my report, but they didn’t really put it in the context of everything else I said or in the context of what I think about conflict of interest in medicine (that the profession should do more avoiding of conflict of interest and less “managing”). I’m quite ethically skeptical of the practice of professional courtesy, as Vertes notes in his final report.

Here are my specific concerns about the College’s Advice:

1) The College expands the definition of professional courtesy beyond the traditional one of colleagues and their families to include also friends and contacts of colleagues. It is not clear what justifies expanding the definition in this way. It sounds like an invitation to the people of Alberta to get on the phone and start working their “contacts.”

Justice Vertes in the Inquiry Report said that he thought there was some scope for professional courtesy, but he explicitly denied it should extend this far. He said:

I accept that physicians are under an ethical duty preventing them from treating themselves or their family members. They must get care from others. So I can also accept that professional courtesy can and should encompass services by one physician to another. In practical terms, that usually means a direct and personal referral. I do not consider this to be improper. I would include in this professional colleagues, such as nurses. But the real question is how widely this practice should apply. I see no justification in labelling as professional courtesy consultations conducted as favours for friends or other contacts. That does beg the question of a two-tiered system (particularly since those services are still charged to the public system). There is no ethical rationale, as in the case of physicians, for extending preferential accommodation to others – at least not under the pretext of professional courtesy. Furthermore, while personal and professional loyalties may be positive values in some contexts, requests for preferential access can pose an ethical dilemma for the health care provider and even create a conflict of interest. (pp. 126-127 of https://www.assembly.ab.ca/pub/PDF/HealthServicesPreferentialAccess_Inquiry_Volume1.pdf)

2) The practice is a holdover from the days when physicians themselves might have been unable to afford care. Not everyone in the profession was prosperous and health insurance was not yet widespread. It is unclear if there is any justification for it in the contemporary world.

3) I take very seriously the stewardship responsibilities of the profession with regard to the citizens and taxpayers of Canada, and so I consider the practice akin to anyone else who is a gatekeeper for services paid for by the public purse using that position to benefit their personal contacts. That is, I see it as a clear conflict of interest that should be avoided, not “managed” as the College Advice recommends.

4) I find it doubtful that the queue-jumping issue can be resolved by saying follow-up care should be on the basis of need, like everyone else. Once the consult or second opinion is in hand, everyone has to act on it—you can’t go back in the queue where you would have been without the special treatment.

5) One might hope that advocacy and going the extra mile to make that phone call or add an extra appointment at the end of the day would be focussed on need (advancing health equity) and not on getting even better access to care for those who already have good access to care. I’ve been calling this “equity-promoting” vs. “equity degrading” differential access since I wrote the report for the Inquiry.

6) There is a whole dimension of boundaries and self-care at stake here, which we often ignore when we focus on the queue-jumping, stewardship, and equity concerns. I think it’s important, but when I talk to the media we don’t always get this far! The Colleges would use agreeing to see a patient outside of office hours as an example of a “boundary crossing”—not yet a violation, but something to pay attention to, as a possible warning sign. There’s a good literature on problems with VIP care—care to anyone influential enough to persuade you to vary your normal approach to practice. (When I talk to physicians about these issues they often link professional courtesy and VIP care.) I like this recent Guzman article: http://www.mdedge.com/ccjm/article/95473/practice-management/caring-vips-nine-principles. Also, relying on professional courtesy can be a warning sign of a deficit in self-care—health care providers avoid seeking care for all sorts of unhealthy reasons, and then they seek care informally under the guise of professional courtesy.

With respect, I think Vertes in the quote above was somewhat unclear about this–he seemed to confuse the idea that people shouldn’t get care from their own physician family members with the idea that they should get their own physician family members to secure them access to care (instead of getting access to care like everyone else does).

To be clear, I don’t think that the existence of professional courtesy is the biggest threat to health equity in the Canadian health care system. Lack of pharmacare has a strong claim for that title. Running neck and neck is the simple fact that we assume that our single-payer “single-tier” system will deliver equity, when we need to track it and act on what we find, which we don’t do very well. Furthermore, an approach to queue-jumping in health care should probably be part and parcel of addressing problems in access to care, and not an isolated punitive policy issue. But the topic does raise the question whether physicians and colleagues are stakeholders in the system like the rest of us, or able to use their insider access to avoid the problems that other Canadians live with.

Even if you think it’s more of a grey area than I think it is, I worry that the College’s advice steers people in one direction rather than giving them an understanding of all the dimensions of the issue to help them fit their approach to their own professional conscience.

 

 

Introduction to the Special Issue: Precarious Solidarity—Preferential Access in Canadian Health Care

Special issue of Health Care Analysis

Systems of universal health coverage may aspire to provide care based on need and not ability to pay; the complexities of this aspiration (conceptual, practical, and ethical) call for normative analysis. This special issue arises in the wake of a judicial inquiry into preferential access in the Canadian province of Alberta, the Vertes Commission. I describe this inquiry and set out a taxonomy of forms of differential and preferential access. Papers in this special issue focus on the con-ceptual specification of health system boundaries (the concept of medical need) and on the normative questions raised by complex models of funding and delivery of care, where patients, providers, and services cross system boundaries.

Read online here: http://bit.ly/2iZclU5

Papers in the special issue:

Reid, L. Medical Need: Evaluating a Conceptual Critique of Universal Health Coverage. Read online here: http://bit.ly/1Og5FP1

Snyder, J., Johnston, R., Crooks, V., Morgan, J., & Adams, K. How medical tourism enables preferential access to care: Four patterns from the Canadian context. Online Access with subscription: http://link.springer.com/article/10.1007/s10728-015-0312-0

Reid, L. Concierge, Wellness, and Block Fee Models of Primary Care. Read online here: http://bit.ly/1WA9wJe

Lanoix, M. No longer home alone? Home care and the Canada Health Act. Online access with subscription: http://link.springer.com/article/10.1007/s10728-016-0336-0

 

Truth or Spin? Disease definition in cancer screening

Are the small and indolent cancers found in abundance in cancer screening normal variation, risk factors, or disease? Naturalists in philosophy of medicine turn to pathophysiological findings to decide such questions objectively. To understand the role of pathophysiological findings in disease definition we must understand how they mislead in diagnostic reasoning. Participants on all sides of the definition of disease debates attempt to secure objectivity via reductionism. These reductivist routes to objectivity are inconsistent with the Bayesian nature of clinical reasoning; when they appeal to the sciences, they are inconsistent with what philosophy of biology tells us about its natural kinds. Proposals that we narrow the scope of our claims in the disease definition debates (proposing adoption of a specific disease paradigm for a specific context) are useful, but paradigms can still distort our reasoning in particular cases, even when we are self-conscious about their status.

On-line first in The Journal of Medicine and Philosophy, http://bit.ly/2pnEndy

Concierge, wellness, and block fee models of primary care: ethical and regulatory concerns at the public-private boundary

In bioethics and health policy, we often discuss the appropriate boundaries of public funding; how the interface of public and private purchasers and providers should be organized and regulated receives less attention. In this paper, I discuss ethical and regulatory issues raised at this interface by three medical practice models: concierge care, executive wellness clinics, and block fee charges, three practice models in which physicians provide insured services (whether publicly insured, privately insured, or privately insured by public mandate) while requiring or requesting that patients pay for services or for the non-insured services of the physicians themselves or their associates. This choice for such practice models is different from the decision to design an insurance plan to include or exclude user fees, co-payments and deductibles. I analyze the issues raised with regards to familiar health care values of equity and efficiency, while highlighting additional concerns about fair terms of access, provider integrity, and fair competition that are raised by providers’ discretionary actions within the context of pooled resources. I then analyze the common Canadian regulatory response to block fee models, considering their extension to wellness clinics, with regards to fiduciary standards governing the physician-patient relationship and the role of informed consent. I close by highlighting briefly issues that are of common concern across different fundamental normative frameworks for health policy.

Online first access, Health Care Analysis. Link to free pdf: http://rdcu.be/nrED

Medical Need: Evaluating a Conceptual Critique of Universal Health Coverage

Some argue that the concept of medical need is inadequate to inform the design of a universal health care system—particularly an institutional (universal, comprehensive) rather than a residual (minimalist, safety net) system. They argue that the concept a) contradicts the idea of comprehensiveness; b) leads to unsustainable expenditures; c) is too indeterminate for policy; and d) supports only a prioritarian distribution (and therefore a residual system). I argue (a) that ‘comprehensive’ understood as ‘including the full continuum of care’ and ‘medically necessary’ understood as ‘prioritized by medical criteria’ are not contradictory, and (b) that UHC is a solution to the problem of sustainability, not its cause. Those who criticize ‘medical need’ for indeterminacy (c) are not transparent about the source (ethical, semantic, political, or other) of their commitment to their standards of determinacy: they promote standards that are higher than is necessary for legitimate policy, ignoring opportunity costs. Furthermore, the indeterminacy of concepts affects all risk-sharing systems and all systems that rely on medical standard of care. Furthermore, (d) the concept of need in itself does not imply a minimal sufficientist standard or a prioritarian distribution; neither does the idea of legitimate public policy dictate that public services be minimalist. The policy choice for a system of health care that is comprehensive and offers as good care as can be achieved when delivered on equal terms and conditions for all is a coherent option.

Forthcoming, Health Care Analysis. Link for free download: http://rdcu.be/nf2w

Answering the empirical challenge to arguments for universal health coverage based in health equity

Temkin (2014) asks how we should distribute resources between the social determinants of health (SDOH) and health care; Sreenivasan (2007) argues that if our goal is fair opportunity, funding universal health coverage (UHC) is the wrong policy. He argues that social equality in health has not improved under UHC and concludes that fair opportunity would be better served by using the resources to address the SDOH instead. His criticism applies more broadly that he claims: it applies to any argument for UHC based on health equity. However, neither his strong causal conclusion nor his stark policy proposal is justified. I review methodological challenges for establishing the relative causal contributions of health care and social policy, concluding that we may never have a robust causal account to support a consequentialist choice. Fortunately, we may not need to answer the allocation question as a dichotomy. Given the multi-dimensional nature of health equity (Sen 2002) and the role of UHC in cost containment, UHC may not compete with social programs for funding. I also argue against Sreenivasan’s claim that the data he discusses should not trouble sufficientists and prioritarians. The worst off are not simply lagging in improvement; rather, their health status is stagnating or worsening.

Sen, A. (2002). Why health equity? Health Econ, 11(8), 659-66.

Sreenivasan, G. (2007). Health care and equality of opportunity. The Hastings Center Report, 37(2), 21-31.

Temkin, L. S. (2014). Universal health coverage: Solution or siren? Some preliminary thoughts. J Appl Philos, 31(1), 1-22.

Public Health Ethics 2015: Free download at http://bit.ly/1NU33m2

Robert Reich on inequality and non-profits

Robert Reich (was Secretary of Labour under Clinton; academic and author) has an interesting discussion of the role of growing inequalities in the non-profit sector, here: http://robertreich.org/post/115695610915. He doesn’t name health care, but I discuss this aspect of growing inequality briefly in my review essay on Piketty and bioethics forthcoming in IJFAB. Reich’s focus is on the effects on academic freedom—the Koch brothers appointing the advisory panel that chooses professors and evaluates the performance of the programs they fund, for example. I would say these arrangements are clearly a violation of academic governance standards. Universities have a common interest in setting standards for the wealthy to meet: those standards should clearly communicate that funding does not buy influence over hiring and program evaluation.

In health care, we discuss physicians, researchers, and drug and device industry influence, but not so much the relationships of health care institutions with donors—who might have a focus on particular clinical conditions, or a particular ideologically-driven approach to health, or favourite research programs. Institutional donors may have influence on purchasing, so there are concerns parallel to the physicians and industry concerns. But what other issues arise? Do they have influence on clinical standards? Do they distort health care planning and priority setting? Does the culture of non-profits—of money-drenched fund-raisers, board membership and wall naming as social capital, and special perks for members—fit with the medical, stewardship, and public service responsibilities of health care institutions?

Prokopetz & Lehman (Yale/Brigham and Young Women’s Hospital) have an article on the pressure fund-raisers put on physicians here: http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001600

And another article by Wright et al. at Johns Hopkins is here (behind paywall): http://link.springer.com/article/10.1007/s11606-012-2246-7.

Does population health have an intrinsically distributional dimension?

Dawson and Verweij (2009) claim that population health has a distributive dimension; Coggon (2012) argues that this presupposes a normative commitment to equity in the very definition of population health, which should, rather, be neutral. I describe possible sources of the distributive view, several of which do not presuppose egalitarian commitments. Two relate to the nature of health as a property of individuals (it cannot be aggregated and exploited like wealth; its absence is more significant than its surplus); two relate to the epistemology and pragmatics of public and population health (social justice is an inherent value of public health practice; public health science and intervention rest on the* clustering to identify causal factors). A fifth source of the distributive view is a critical stance on the concept of population health; I contrast this with Coggon’s account of the public as a shared political imaginary. None of these views are “neutral”: they exhibit several different kinds of normativity and quasi-normativity, but this is not problematic. Finally, I argue that the critical stance appropriately distinguishes and relates social justice and public health.

Advance access–free! at Public Health Ethics: http://bit.ly/1iRD7fK

*Don’t you hate it when you notice your editing error after an article is published?

Piketty, politics, and social policy at the LSE

Folks in the Comparative and International Political Economy group at the LSE organized an afternoon workshop on what Piketty’s data and claims about growing inequality mean for politics and social policy.

I came down from my sabbatical perch at Birmingham to attend the sessions–this week, the IJFAB blog will be posting my four posts from the sessions.

First one today, introducing Piketty and what the day is about: http://bit.ly/1Liuoji.

Second one, discussing some criticisms from economists: http://bit.ly/1BPKRUt. In this one I talk about real estate, so I got a lot of new twitter followers from this.

Third, discussing Piketty and political science: http://bit.ly/1MQ8XTU.

Fourth, discussing Piketty and social policy (early childhood education) and global perspectives on oligopolies: http://bit.ly/1OqOsPv.

Piketty and the Body: On the Relevance of Wealth Inequality to Bioethics

In Capital in the Twenty-First Century, Thomas Piketty argues that markets, absent political intervention, tend toward economic divergence and that this has deleterious consequences for democratic ideals of equal voice and meritocracy. His goal is to foster a public conversation about what a society dominated by wealth—which we are already beginning to experience as the twenty-first century begins—would look like if we wish to maintain an egalitarian ethos. His work will contribute to and further motivate several discussions in feminist bioethics, namely, on the funding and organization of care labor, reproductive rights, global health, and commodification.

Published in IJFAB, Vol 8 No 2: http://bit.ly/1UT4oKU