Letters to the editor.

Dear Editor,

I enjoyed the article written by Michael Patmas titled "Unexplained Clinical Variance: Are Health Plans (Partly) Responsible?" (The Physician Executive, March/April, 32(2), 2006.)

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Like many quests, the desire to do the right thing using the best evidence involves a search for truths. Who has the evidence that can be used to make the right decision and where do these truths reside? He gives some excellent sources of medical evidence. Often however, interpretations of the "truth" can vary depending on who is performing this task.

Evidence-based medicine, however, also has its limitations. As someone who is mostly involved with medical education, I am the first one to ask residents and medical students for evidence on which they base their decisions.

Sometimes, however, no such evidence exists to help determine the best course of action for the particular clinical situation. This is where judgment takes over.

Even when it comes to double-blinded, placebo-controlled randomized clinical trials, all is not well. Some of my colleagues have argued that the applicability of these trials to their patients is lacking. The data can always be attacked, and determining the best evidence is not an easy proposition.

Determining medical necessity is not always easy. I have performed work in utilization/medical necessity for a local IPA. Our medical group contracted for this work. To their credit, occasionally they would give us each the same 10 cases to test inter-rater decision-making. I thought this a very scientific approach. On a small scale this IPA demonstrated interest in determining how variability at the health plan affected practice patterns.

This, however, is just the beginning.

Patmas proposes bringing together health plans' medical directors to start work on the issue, a great step in the right direction. Standardization in the structure and writing of benefits policies once the best evidence is found might also help since it is this information that is often used to make decision.

Determining the degree of variability among medical directors in their decision-making might involve administering "dummy" cases to determine the contribution to practice pattern variability. It might be found that they parallel each other in certain areas of the country.

With a lot of work, this might lead to standardization in the approach to determination of medical necessity and a lot of kudos from our practicing colleagues.

Jose A. Perez, Jr., MD, MBA, MSEd, FACP, CPE 

Bakersfield, Calif.

Dear Editor:

My friend and fellow ethicist, Richard Thompson, MD, wrote an excellent and readily understandable introduction to principal-based ethics and moral intelligence, the latter being a reclaiming of the traditional "virtue ethics" ("Look What's Happened to Medical Ethics," The Physician Executive, 32(2), March/April 2006).

Indeed, the ethics of health care are distinctive. As Tom Beauchamp and James Childress have famously asserted, and as Thompson emphasizes, philosophical theories of moral absolutes do not necessarily serve well as a basis for the multiple dimensions of health care ethics. (1)

However, I would challenge Thompson to go much further in discussing "what's happened to medical ethics." The brave new world of 21st century health care ethics both affirms and challenges the adequacy of not so new concepts like principle-based ethics and moral intelligence as frame-works for considering ethical decisions.

The field of narrative ethics has highlighted the value of patients telling their stories of illness, both for their own healing and for the sake of the physician-patient relationship. (2)

Feminist health care ethicists rethink existing ethical questions and pose new ones; they highlight the importance of context, long-term relationships, and grounding theory in ordinary experience. (3)

Voices from religious ethics communities offer resources for recovering language of community and rethinking the familiar grounds of social justice debates in forming an ethical response to the American health care reform crisis. (4)

The health care ethics conversations of the 21st century are richly diverse and vibrant. As a lifetime member of the ACPE, I hope that future Physician Executive articles and "Ethical Aspects" columns introduce readers to the depth, breadth and wealth of these conversations.

Bettina B. Kilburn, MD, M.Div.

Atlanta, Ga.

References

1. Beauchamp, TL and Childress JF. Principles of Biomedical Ethics, 4th Edition. Oxford University Press, New York, 1994.

2. Charon R. "The Physician-patient relationship. Narrative medicine: A model for empathy, reflection, profession, and trust." Journal of the American Medical Association, 286(15), 1897-902, Oct. 17, 2001.

3. Warren V. "Feminist Directions in Medical Ethics," in Holmes HB and Purdy L. Feminist Perspectives in Medical Ethics. Indiana University Press, Bloomington and Indianapolis, Ind., 1992.

4. Ashley BM and O'Rourke BM. Health Care Ethics: A Theological Analysis. 4th Edition. Georgetown University Press, Washington, D.C., 1996.