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May 2, 2012

Patient Requests for Nonbeneficial Care—Reply

Author Affiliations

Letters Section Editor: Jody W. Zylke, MD, Senior Editor.

Author Affiliations: Department of Medicine, University of South Carolina School of Medicine, Columbia (Dr Brett) (; Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas (Dr McCullough).

JAMA. 2012;307(17):1797-1798. doi:10.1001/jama.2012.3611

In Reply: We agree with Dr Cassel that new approaches that represent physician-led improvement in medical decision making may be beneficial for physicians and are consistent with the principles articulated in our essay.

Dr Laws raises 2 interesting points for consideration. First, to deter patients from making requests for inappropriate clinical management, she proposes that patients should have more financial skin in the game. This proposal has initial appeal for physicians because it would make things easier for physicians in selected cases: Patients would likely make fewer requests for inappropriate tests or treatments. On closer examination, however, there is serious ethical risk. When patients already have co-payments and deductibles that are high enough (and going higher) to dissuade them from seeking unnecessary care, they may also be dissuaded from seeking and implementing necessary medical care. This problem should not be exacerbated. The primary responsibility for managing the inappropriate requests from patients rests with physicians who should respectfully assert their professional integrity. This approach strikes a balance between providing effective medical care, respecting patients' preferences for reasonable interventions, and protecting patients from making bad decisions.