http://abcnews.go.com/sections/living/GoodMorningAmerica/medicalinfo030708.html

By Caroline Stanculescu

Of these doctors, 35 percent were doing so more often than they had in the five years leading up to the 1998 survey. Doctors whose patients were largely poor and unlikely to get appropriate help from their health plans often fall short on disclosing information. The study is published in the latest issue of Health Affairs.

But according to the AMA's code of medical ethics, "physicians have an obligation to assure the disclosure of medically appropriate treatment alternatives, regardless of cost," so why would doctors withhold important and potentially lifesaving information?

Reasons for Rationing

According to the study, doctors are often caught between their obligation to provide information and their fear of being asked to cheat insurance companies so that patients can receive care they are not eligible for — a practice called "gaming the system."

It is also suggested that doctors whose revenue is significantly tied to managed care companies tend to hold back information about non-covered treatments to some patients.

Many doctors contacted by ABCNEWS cited time constraints as the number one difficulty. Dr. John Messmer of Penn State Hershey Medical Center says doctors are now expected to explain complicated medical information to patients while having less and less time to do so. They are caught between their duties to their patients and their lack of resources.

"The ethical issue is that we no longer work for patients since we are no longer paid by them. Practitioners who want to be compensated must follow the insurance company's or government's rules, even if we disagree with them," says Messmer.

An Ethical Dilemma

Whether or not a doctor should inform a patient of other, uncovered treatments can be a medical dilemma for doctors and bio-ethicists. Medical ethicist Maxwell Mehlman, Director for the Law-Medicine Center at Case Western Reserve University, says that a doctor's motivation to self-censor could simply be based on human compassion. For example, if there is no reasonable expectation that a patient may have access to certain treatment, is it justifiable or cruel to tell the patient about these options?

"Why even mention an implantable defibrillator or organ transplant to someone who could never in a million years afford it and whose insurance or lack of it doesn't cover it?" says Dr. James Mold, director of Research at the University of Oklahoma Health Sciences Center.

Mold says that while it is important to ascertain whether a patient can raise money for treatment, there are "certainly circumstances where it seems inappropriate to tell someone that there is a treatment available but they can't have it."

But others disagree. Dr. Susan Door Goold, Director of Bioethics at the University of Michigan, maintains that any censoring of medical information, even unintentional, is wrong, and that clinical decisions should never be based on assumptions about the patient or the patient's medical insurance. "What if the doctor is wrong about the coverage? What if the patient, unbeknownst to the doctor, has other resources she could use," says Goold.

Charles Inlander, president of the consumer advocacy organization People's Medical Society, concurs and notes that while many plans do not cover liver transplants, thousands of these procedures yearly are funded through private donations.

Inlander believes doctors should never presume what a patient may or may not be able to afford. "Finances is not an ethical issue; treatment is," says Inlander, "doctors should not consider cost issues when discussing potential treatments."

Go Ahead and Ask

To begin, experts advise patients to always ask their doctor directly to tell them what all their treatment options are. Medical practices can also help in determining which treatments are covered.

Goold encourages patients to empower themselves by researching conditions and treatments on their own, and bring questions to their doctor appointments — "No one is as interested and invested in your health as you are," says Goold. The Internet, local libraries, and medical advocates are all useful references for patients looking for more information, but be wary of sources that are not accredited.

"One of the best ways to ensure that patients hear everything is to get a good second opinion, since the majority of doctors do not withhold information," advises Dr. Carolyn Eaton of the Palacios Family Practice Clinic in Palacios, Texas.

 
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