Case example

Dr. Moore is a gastroenterologist working in a large multi-specialty private medical practice. One of his long-term patients is Father Nolan, a 54-year-old Episcopal priest with chronic hepatitis C virus (HCV) infection. Father Nolan contracted this infection more than twenty-five years ago, probably through a blood transfusion, and he has had slowly progressive liver injury over the past two decades. Until very recently, the only available drug treatment regimen for HCV infection was lengthy, arduous, and only partially effective. Father Nolan began this treatment regimen five years ago, but suffered severe complications and had to discontinue the treatment.

A new drug, sofosbuvir, has just been approved for the treatment of HCV infection. The early evidence suggests that this new drug is a genuine medical breakthrough. Treatment with a combination of sofosbuvir and other medications is short in duration, is well tolerated, and has a more than 95 percent cure rate. Dr. Moore would prescribe the new drug for Father Nolan right away, but for one stumbling block – the cost of the treatment regimen is about $140,000. Father Nolan has private health insurance; his parish provides this insurance to its staff through a non-profit insurer that specializes in health insurance plans for small religious institutions. In an attempt to control its costs, the insurance company has placed strict limits on who can be reimbursed for this drug, reserving it for only those patients with severe liver disease who need immediate treatment. The company has decided that its many other chronic HCV patients can wait until competing drugs now being developed by other manufacturers enter the market over the next few years, and the subsequent competition drives down drug prices.

Father Nolan does not meet his insurer’s strict conditions for receiving the new HCV treatment. He is not acutely ill, but he does have continuing symptoms caused by liver damage, including fatigue, loss of appetite, and swelling in his lower body. Dr. Moore believes that his patient would clearly benefit from receiving the new treatment as soon as he can. He is considering several options. He could report exaggerated symptoms to the insurance company in order to make Father Nolan eligible to receive the new treatment. He could inform Father Nolan about the new treatment and about the insurance company’s decision not to cover it in his case. Or, he could decide not to mention the new drug treatment, continue to provide symptomatic treatment, and wait for the expected release of new HCV drugs and for a change in the insurance company’s treatment eligibility rules. How should he proceed?¹

Resource stewardship is the most recently recognized, and therefore probably the least well understood, of the moral foundations of the therapeutic relationship examined in Part II of this volume. In 1997, the Board of Directors of the American College of Emergency Physicians (ACEP) approved a new document developed by its Ethics Committee, entitled “Code of Ethics for Emergency Physicians.”² Previously, ACEP had endorsed the American Medical Association’s “Principles of Medical Ethics,”³ but the “Code of Ethics for Emergency Physicians” includes a new and distinct set of ten “Principles of Ethics for Emergency Physicians,” which it describes as “fundamental moral responsibilities of emergency physicians.” Several of the new ACEP principles of ethics are similar to principles in the AMA list, but others are entirely different. Among the novel principles in ACEP’s list is the following: “Emergency physicians shall serve as responsible stewards of the health care resources entrusted to them.” This is, to my knowledge, the first formal statement of a duty of resource stewardship in the ethics code of a professional society of physicians or other health care professionals. In its description of this duty, the ACEP Code observes that “the emergency physician has dual obligations to steward resources prudently while honoring the primacy of the patient’s best medical interests.”

One year later, in the 1998 fourth edition of its “Ethics Manual,” the American College of Physicians also recognized a duty of resource stewardship, in the following passage:

The AMA has also recognized a duty of resource stewardship, but its recognition came much later. In 2012, it issued “Opinion 9.0652 – Physician Stewardship of Health Care Resources.”⁵ That opinion includes the following description:

These representative professional association statements indicate growing acceptance of a duty of resource stewardship, but they also suggest several important questions. Why did appeals to this duty emerge in the late 1990s? What exactly is meant by a duty of stewardship? Why is stewardship a duty of health care professionals? Each of the above statements links stewardship with the duty to promote the best interests of individual patients – how do these two duties relate to one another? This chapter will explore the origins, meaning, proposed criteria, and scope of the duty of resource stewardship.

Origins of the duty

A brief look back at the recent history of health care can shed light on the emergence of a professional duty of resource stewardship. Over the past century, health care in the United States and the rest of the developed world has undergone a remarkable transformation.⁶ In the first half of the twentieth century, health care was largely a cottage industry, with care provided by individual practitioners in patients’ homes or in small physician offices. Available treatments were limited, inexpensive, and “low-tech,” and patients usually paid for their care in cash out of pocket.

Following World War II, however, health care entered an era of major innovation and expansion, with rapidly increasing public and private spending on biomedical research and easier access to care via personal health insurance. The investment in research produced multiple new and effective treatments in every medical specialty, and the growth of health insurance made those new treatments available to larger numbers of patients. By 1980, New England Journal of Medicine editor Arnold Relman proclaimed the emergence of “the new medical-industrial complex” – US health care had become a highly complex, multi-billion dollar industry.⁷

The US health care system enjoyed extraordinary success and prosperity during this period, but it also confronted two persistent problems. First, despite the growth of private and public systems of health insurance, forty to fifty million US residents still lacked insurance and easy access to health care, and this contributed to significant health disparities.⁸ Second, spending on health care increased relentlessly, consuming an ever-larger share of the entire US economy, and straining the budgets of both public and private payers.⁹ By 1992, presidential candidate Bill Clinton asserted that the United States faced a “crisis” in health care and pledged to reform the US health care system.¹⁰ Despite Clinton’s election victory, his complicated plan for national health care reform never gained much support in a divided US Congress. Instead, employers and government turned to market-based managed care organizations to control their health care costs. These organizations employed various mechanisms to “manage,” and usually to restrict, the choices of both patients and health care providers. Managed care plans grew rapidly in the 1990s, but the restrictions they imposed were highly unpopular.¹¹ Strong public and professional backlash against managed care resulted in multiple legislative restrictions and widespread rejection of managed care health insurance options.

Prior to this time, the prevailing opinion was that health care professionals should make treatment decisions based only on the best interests of their individual patients, and should leave decisions about the allocation of health care resources to health system officials and to legislators.¹² It was in this late-1990s period, however, that appeals to a professional duty of resource stewardship began to appear. By then, there was growing consensus that the long and steady growth in US health care spending was unsustainable, and so cost containment was essential. A major government initiative to control costs, the Clinton health care plan, had failed, and market-based managed care initiatives were under sustained attack. If neither government nor the market could (or should?) control the costs of health care, commentators and professional societies proposed that health care professionals, and especially physicians, should assume this responsibility.¹³ Although payments to physicians are a relatively small proportion of total personal health care expenditures, physicians’ decisions, about diagnostic testing, treatment, referral to other providers, and hospitalization, among others, are major determinants of the use and the cost of care.

In one obvious sense, physicians are in the best position to determine whether a test or a treatment that they are considering for a patient would be a good use of resources, including the necessary personnel, medical supplies, medical equipment, and the money to pay for those personnel, supplies, and equipment. Physicians can make these decisions based on their first-hand knowledge of the patient, his or her medical condition, the different treatment options, and the likely consequences of those options. Recall that, except for their own time and effort, the resources in question in these treatment decisions almost always do not belong to the physicians who prescribe their use, but rather to whoever will pay for them, usually a government- or employer-funded insurance program, and often the patients themselves. These payers make multiple decisions about the resources they control, as, for example, what treatments are covered under Medicare or under a private health insurance plan, and what treatment an individual patient is willing to pay for. They may also, however, call on health care professionals to make wise use of their resources as a condition of authorizing those professionals to allocate those resources for the care of their patients.

Concepts and criteria

The term ‘steward’ is used in a variety of different ways – think, for example, of wine stewards in restaurants, cabin stewards on cruise ships, and shop stewards in unionized factories. More similar to the contemporary use of stewardship language in health care, however, are prominent appeals in Christian theology. The New Testament records several parables about stewardship told by Jesus to his disciples.¹⁴ In these parables, a wealthy man entrusts resources to servants and later demands an accounting from each servant of the resources entrusted to him, praising those who used the resources to increase the master’s possessions and condemning those who failed to do so. Christians interpret these parables as exhortations to make wise use of God’s creation, including both individual and shared resources. In similar fashion, calls to resource stewardship in health care direct professionals to make wise, or prudent, or responsible use of the health care resources entrusted to them. This claim seems obvious – of course we want health care professionals to be responsible and to practice the virtues of wisdom and prudence. The claim is also quite vacuous, however, because it does not specify what constitutes responsible, wise, or prudent use of health care resources. To make resource stewardship a useful guide to action, more substantive principles or criteria are needed. Choosing more specific criteria for resource use, and defending those criteria, are much more difficult and controversial tasks, however.

There are surely multiple ways to approach the task of giving content to a duty of health care resource stewardship; here is one such approach: In the Biblical parables cited above, stewards are praised and rewarded for using resources to further the interests of their masters, who are the owners of the resources. The lesson of these parables seems clear – Christians should recognize that they are not owners but stewards of God’s creation and should use the resources available to them in accordance with the divine will. If we apply this general understanding of stewardship (namely, attending to the interests or wishes of the resource owner) to health care, we can conclude that health care professionals should use the resources entrusted to them to promote the interests or carry out the wishes of the resource owners.

Who, then, are the owners of the resources devoted to health care, and what are their interests and wishes? There are, of course, multiple owners of these resources, both public and private, and both corporate and individual. And, these owners have multiple interests and wishes, sometimes shared and sometimes unique or distinctive. If the interests and wishes of these resource owners were highly diverse, it would presumably be impossible to formulate criteria that are both substantive and broadly applicable, and professionals would instead have to examine each situation individually. If, however, the various owners of health care resources have many substantive shared interests and wishes, it may be possible to identify at least some general criteria of stewardship based on those shared interests.

There are, in fact, a number of important interests and goals that are shared by virtually all the major owners of resources devoted to health care, including public health insurance programs like Medicare and Medicaid, private-industry-funded health plans, public and private health care facilities, manufacturers of pharmaceuticals, medical devices, and medical equipment, and individuals who purchase health care for themselves and their families. Perhaps most prominent among these shared interests is the provision of safe and effective health care services for the individual patients who need and can benefit from them. Also very prominent for corporate public and private payers is promotion of the overall health of a group of people, as, for example, all of the members of a health maintenance organization, or all of the employees and their dependents covered under an employer-provided health insurance plan. All of these resource owners also share an obvious interest in achieving their goals of promoting individual and population health in the least costly way, in order to conserve their limited resources and to insure their solvency and their continued existence. (For-profit health care corporations have an additional, distinctive goal for controlling spending, namely providing a return on investment to their private owners or their shareholders.) Finally, the major owners of health care resources appear to be willing to honor at least some choices of both patients and health care professionals, even if those choices do not optimize health outcomes, conserve resources, or maximize profits.¹⁵

Even though the interests described above are widely shared, an obvious problem with using them to identify specific criteria for making stewardship decisions is the fact that the different interests can and often do conflict with one another. Because that is the case, a decision that promotes one interest (for example, providing a very expensive new chemotherapy treatment that benefits an individual patient) may interfere with achieving another interest (for example, initiating a local smoking cessation program to improve the health of a specific population). Nevertheless, scholars have proposed a number of candidate criteria to guide resource use, including refraining from fraud and from wasteful services, choosing the most cost-effective treatment option, avoiding the use of marginally effective or “low-value” treatments, and rationing unavoidably scarce resources fairly. Let us consider each of these criteria in turn.

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