Some benefit, but at a high cost? Patients deserve “even-handed” description

Providers face difficult decisions on treatments

The continuing development and dissemination of high-cost medical treatments poses significant ethical questions regarding access to health care and just distribution of the benefits of these treatments, according to John C. Moskop, PhD, chair of the Clinical Ethics Committee at Wake Forest Baptist Medical Center in Winston-Salem, NC. The potential benefits of medical treatments, including new, high-tech, high-cost treatments, are virtually unlimited — that is, they can prolong life, or improve function or quality of life, for at least some patients, he says.

“The resources we can devote to providing these treatments, though very substantial, are limited by our ability or willingness to pay for them,” says Moskop. “We are loathe to deny beneficial treatments to patients, even when those treatments are very costly. But at some point, we — as individuals and as a society — simply cannot afford to provide those benefits.”

Cost-benefit ratio

High-cost treatments might have a much poorer cost-benefit ratio than very effective, low-cost treatments, notes Moskop. “We are not talking about what is sometimes called ‘futile’ or ‘wasteful’ treatment that confers no benefit for the patient,” he explains. “Rather, we are talking about treatments that are able to provide some benefit for some patients, such as a short prolongation of life, or some relief from suffering, but at a very high cost.”

The question is how providers can decide which high-cost treatments to provide and to forgo, and who should make these decisions, says Moskop. Treatment providers, including individual health care professionals, health care facilities, and drug and device manufacturers, might have vested interests in providing these treatments, if their income is linked to the number of treatments provided.

“So there is some risk that patients may not be given adequate and objective information about all of their treatment options, or may be manipulated into accepting high-tech treatments that they would otherwise forgo,” Moskop says.

Guaranteed access?

Patients deserve an even-handed description of all of the recognized treatment options for their condition, argues Moskop. Many will choose the expected benefits of less costly treatment plans, such as hospice care, over the expected benefits of high-cost treatments that offer short-term prolongation of life.

“Some patients, however, will seek out and choose any treatment, no matter how costly, that offers some potential for life prolongation,” says Moskop. “Should access to such treatments be guaranteed? Or should it depend on the individual patient’s ability to pay for the desired treatment, or on the patient’s private or public health insurer’s decision to cover the high-cost treatment?”

Implementation of the Affordable Care Act will give many more patients access to health insurance, but it will also pose difficult questions about what should be included in the essential benefit package of approved health insurance plans. It is still unclear how the reformed U.S. health care system will expand access to care and control health care costs without making difficult decisions about the coverage limits, says Moskop.

“Adopting limits on coverage — ‘rationing’ treatments — will meet strong resistance,” he predicts. “But if most or all new high-cost treatments must be covered, the costs of the system will likely not be contained, and the reformed system will not be sustainable.”


• John C. Moskop, PhD, Chair, Clinical Ethics Committee, Wake Forest Baptist Medical Center, Winston-Salem, NC. Phone: (336) 713-4156. E-mail: