Mrs. Chilaca is 67 and has severe peripheral neuropathy from diabetes. She has tried antidepressants, massage, narcotics, anti-inflammatory agents and antiepileptics. She has been to a chiropractor for several adjustments, without success. The only medications she takes are metformin and glyburide.
Her examination shows no hair below the knees, poorly palpable dorsalis pedis pulses and absent posterior tibialis pulses bilaterally. Her shiny, smooth skin is insensitive to touch or pain. There are no cracks between her toes. Her glycohemoglobin was 6.7 when checked two months ago.
"What about hot peppers?" she asks Dr. Beale. "My granddaughter says they aid circulation — all I do is dry and powder them in a blender and make a liniment. Or how about if I just add some salsa to my eggs in the morning? Yum!"
What doing good once meant
Beneficence means doing good, and until managed care, medical treatment meant an urgent, immediate, rule-out, disease-centered response.
At its most thoughtful, managed care understands physicians' duty to do good. Imagine you're on the banks of a river when suddenly, fully-clothed people bob past, swimming to reach shore. Instead of just pulling people out of the river, reasons managed care, why not go upstream to see why they're falling in?
How has doing good changed in the managed care era? Does objective information for diagnosis and treatment still come first in decision making? Can a physician do good for people whose only unifying characteristic is that they found his name in a book?
How beneficence has changed
Old-style beneficence has taken a back seat to patient autonomy as the most important principle in managed care. Doing good is no longer a disease-centered effort. Instead, it is person- and population-centered, and because it is both it is tricky to master.
Beneficence is customer-focused, cost-conscious and flexible. It asks that physicians help whole populations avoid expensive treatments when possible and emphasize basic, cost-effective treatments.
To do good in managed care, physicians must develop the conviction that public health should be integrated into ordinary medical practice. Physicians must help patients educate themselves, and give them and their families a bigger decisional role.
In short, beneficence will look a lot more like self-help than paternalism. And in most cases, it should. The exceptions: patients who cannot act for themselves, are on the margins of the system, are uneducated or are illiterate. For these patients, clinicians cannot afford to let self-help carry on by itself.
Doing good has never included allowing access to futile treatment. Ethical arguments about futility are much ado about little; financial arguments are central to futility in managed care.
The real point about futile treatment is to identify it before it is instituted, clarify its uselessness and avoid it. Here is an issue on which clinicians and managed care organizations can agree: Treatment that is neither medically effective nor personally beneficial is wasteful, has no business being administered and in many cases can be prevented.
Inappropriate and futile treatment would rapidly go the way of radiotherapy for tonsilomegaly if medicine could publicly define futility's medical boundaries. But medicine has not done so.
The no-decision decision
For example, a 52-year-old woman comatose for four years develops stage IV pressure ulcers. An internist refers her for wound healing and surgery. A surgeon makes the repair. If a physician will do it and an insurer will pay for it, then neither medicine nor managed care has decided it is futile.
Physicians should be willing to be clear about what works and what does not*and stick to their guns. If medicine is to be shaped by a commercial ethos and defined by efficiency, then the least physicians can do is to be scientific. Let legislators fume about the consequences of studied, unified medical judgment. (For more on the fuming of legislators, see this month's cover article)
Taking a stand
The beneficent approach? Principled stands against tobacco, violence and profiteering. Principled stands for better pain relief, better access, uniform cholesterol screening, more mammograms and mandatory seat belts and safety helmets. Accountability and incentives for physicians and patients who do their part. Practice ethics by principle — no exceptions.
"Hmm. . . chilies. Capsaicin is the chemical that makes hot peppers hot," Dr. Beale says. "It's available over the counter in a cream. Use gloves. Put it over the area at least three times a day for four weeks. Try to avoid touching your eyes, nose or mouth afterwards. Be careful — it stings at first. You don't have to dry and powder chilies yourself; you'll never know how much you have, and if you inhale the stuff we may end up having to put you in the hospital."
What can clinicians in managed care today do about doing good?
1. View beneficence as a way to reinforce patients' abilities to decide for themselves, especially about behaviors related to life style and wellness issues.
2. Link participation to decision making.
- Ask patients to bring blood pressure, blood sugar, exercise and diet logs to the office.
- Write agreed-upon "quit smoking" dates in the record.
- Ask those who can to participate more in their own care.
Clinicians are not there just to pick up the pieces when patients go into renal failure, develop claudication or become ketoacidotic. Clinicians are there to prevent those problems by helping patients become active partners in maintaining their health.
"Rescue me" is how physicians did good until the advent of managed care. "Teach me to swim" is what lies ahead. But right now there are a lot of people in the water, and more are falling in. That's the immediate problem.
Physicians who evaluate a plan's effect on quality of care, then take on the responsibility for treatment and prevention, can keep members healthy and do good for the whole.