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May 11, 2011

Patient Autonomy and Clinician Integrity in Treatment Decisions

JAMA. 2011;305(18):1861-1862. doi:10.1001/jama.2011.585

To the Editor: Dr Lantos and colleagues discussed conflict between patient autonomy and clinician integrity in the case of a young man only days from death, conflict that occurred because the team advised not hospice care but intensive care.1 Cost was mentioned tangentially in a comment about how outside parties, including insurance companies, may limit therapeutic options. Consideration of treatment options without considering cost is common. In a discussion of mammography recommendations, Quanstrum and Hayward2 suggested not recommending care that causes a net harm but leaving decisions about care offering minimal benefit to individual clinicians and their patients, with no mention of cost. Quill et al3 discussed treatment preferences of patients with severe illness who want “everything,” again without mention of cost. In contrast, in an article on the role of chemotherapy at the end of life, Harrington and Smith4 specifically discussed reimbursement and economic issues and concluded that, “unless resources are unlimited, patients and families (or society at large) may be asked to balance individual patient needs against those of society.”

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