Ethics and Choosing Wisely

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The primary ethical obligation of doctors and health professionals to their patients is to give primacy to the best interests of those patients. In “Good Medical Practice”, the code of ethics adopted by the Medical Board of Australia, this is expressed in the following paragraphs:

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Doctors have a duty to make the care of patients their first concern and to practise medicine safely and effectively.
and
In clinical practice, the care of your patient is your primary concern.
This clear priority for an individual patient’s welfare has long been an ethical touchstone of ethical professional health practice.
For this reason, other ethical responsibilities of health professionals have been less prominent. The principles of medical ethics have been identified as beneficence, non-maleficence, respect and justice. The first three can readily be related to the exercise of the primary responsibility for patients’ welfare. The principle of beneficence is fulfilled by ensuring care that improves or restores a patient’s health, the principle of non-maleficence is fulfilled by avoiding patient harm and the principle of respect is fulfilled by accepting a patient’s autonomy to make choices about treatment that is offered.
However, the principle of justice has a wider reference. To some degree, this is expressed in “Good Medical Practice” in the following passages:
Doctors have a responsibility to protect and promote the health of individuals and the community.
and
Good medical practice involves:

5.2.1 Ensuring that the services you provide are necessary and likely to benefit the patient.
5.2.2 Upholding the patient’s right to gain access to the necessary level of healthcare and, whenever possible, helping them to do so.
5.2.3 Supporting the transparent and equitable allocation of healthcare resources.
5.2.4 Understanding that your use of resources can affect the access other patients have to healthcare resources.

Central to the concept of justice in relation to resources is that an allocation should be fair. However it can be difficult to determine what are the correct criteria for a fair allocation.
They can be any one of:

• To each person an equal share


• To each person according to need


• To each person according to effort


• To each person according to contribution


• To each person according to merit


• To each person according to free-market exchanges

The tension between the primary responsibility to individual patients and the responsibility to manage healthcare resources in accord with any of these criteria will be apparent. The tension has frequently been resolved in favour of the duty to the individual patient. In a substantially publicly funded healthcare system such as in Australia, a likely assumption is that determinations about the allocation of resources are made at institutional, regional, state or federal levels and not by individual health practitioners. Although it has been difficult to formulate clear guidance on how individual health professionals can fulfil a responsibility for the fair allocation of health resources, it is increasingly clear that individual decisions can significantly affect planned resource allocations.
Choosing Wisely as a program seeks to address this tension.
It does so by focusing on the link between the professional obligation to maintain and act on current knowledge on the one hand and choosing treatments and tests of proven efficacy that benefit patients on the other. The fact that a test or treatment has been conventional practice and is what patients expect or assume is standard practice needs now to be balanced against the evidence that supports or does not support the efficacy of those tests and treatments.
Patients have a well-established ethical and legal right to refuse proffered treatment, even in the knowledge that in the absence of that treatment they will suffer avoidable harm or even death. This ethical and legal right is an expression of the underlying ethical principle of respect for patient autonomy.
However, the right does not extend to requiring treatments to be offered by health professionals. It is the professional’s duty to exercise skill and judgement in the context of a patient’s condition to offer those treatments or tests.
The Choosing Wisely program is based on fundamental and well-established ethical principles of professional responsibility for individual patient care but, in the exercise of that responsibility, brings into sharp relief the additional duty to be satisfied that recommended or offered tests and treatments are appropriate. What Choosing Wisely promotes is the importance of seeking an objective basis upon which to make the judgement of appropriateness: a basis of evidence of clinical efficacy.

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“This clear priority for an individual patient’s welfare has long been an ethical touchstone of ethical professional health practice.”

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Colin Thomson
BA, LLB, LLM (Sydney)
www.ehealthinfo.gov.au
Colin Thomson, BA, LLM (Sydney) is Professor of Law at the University of Wollongong and Academic Leader for Health Law and Ethics in the Graduate School of Medicine. He also works as a consultant.
He was a member of the Medical Research Ethics Committee (1988-91) of the National Health and Medical Research Council and, from 1998-2002 a member, and from 2006-2009, chair of the Australian Health Ethics Committee. As a consultant, he has advised NHMRC, FaHCSIA, Health Departments of NSW, Qld and Vic and several universities. Heis a Senior Consultant with Australasian Human Research Ethics Consultancy Services (www.ahrecs.com).
Colin has provided training to human research ethics committees, chairs the CSIRO Social Science HREC and is a member of HRECs at Department of Health and Ageing and University of Wollongong/Illawarra Shoalhaven LHD.
He is a joint author of Good Medical Practice: professionalism, ethics and law, 2010, Cambridge University Press.