Values and Covenants

As has been noted several times on this blog, there is much current discussion of what constitutes “value” in medical/health care.  This is not surprising given the concerns about how much (one-sixth) of the US’s overall economic output is spent on doctors, hospitals, drugs, imaging tests, etc. in the name of getting and keeping Americans well.   One might pause to ask how the language of “value” frames a range of conversations about biomedical ethics, just as the language of “rights” has been doing for some time now.

Several, if not most or all, of this blog’s regular contributors would probably subscribe to the view that medicine is, at its core, defined by a “covenantal” relationship between physician and the individual patient, in which the patient, with various needs that rest on a foundation of basic and robust human dignity, encounters the physician who “professes” not just knowledge and skill but also a set of assumed duties toward the patient, for the latter’s highest medical good.  That good is discovered, as it were, in the physician/patient relationship, and pursued as its desired outcome, but the relationship is what is fundamental.  I believe this is an all-too-brief but fair summary.

“Value” strikes me as an economic term that is about outcomes over relationships.  Leaving aside for the moment the question of the needs of an individual patient vs patients in general, the language of “value,” as opposed to “values” (construed as “things we care about”) seems to sit necessarily in tension with the language of “covenant,” with the latter easily becoming quite coincidental to the conversation.  So far, nothing new, as the many posts by Drs. Joe Gibes, Susan Haack, and other physicians on this blog demonstrate.  But I still think it is worth considering that the apparently inescapable terminology drags us in a direction that we might choose to resist.

Against that backdrop, consider two recent, prominent definitions of value in medicine.  The first is from the 2010 New England Journal of Medicine article, “What is Value in Health Care?” by Michael Porter of Harvard Business School.  In that essay, he defines “value…as the health outcomes achieved per dollar spent.  This goal is what matters for patients and unites the interests of all actors in the system…the creation of value for patients should determine the rewards for all other actors in the system.”  What matters are “results, not inputs,” and we might slip, or be pushed, into thinking that “covenant” is an “input,” although we might offer that the conscientious, faithful physician provides care as judiciously as possible.  Outcomes are “inherently condition-specific and multidimensional,” to which we might add often patient-specific and hard to measure.  But I would say that Porter’s definition has the merit of being patient-centered.  I think this is important for the many “actors” in, say, the pharmaceutical industry—people like chemists, project managers, regulatory affairs professionals, business developers, etc.—who don’t take anything like a Hippocratic Oath, and who arguably do not bear the same duties to efface their self-interest as the physician, but who nonetheless work in an enterprise that sits, as it were, under a “Hippocratic umbrella.”

The second definition of value comes from another 2010 paper, this one in The Oncologist, specifically addressing cancer care.  The definition is readily attributed to the paper’s lead author, Scott Ramsey of the University of Washington.  An intervention “[has] value if patients, their families, physicians, and health insurers all agree that the benefits afforded by the intervention are sufficient to support the total sum of resources expended for its use.”  Since modern medicine is so darned complex and expensive, making claims and placing burdens on a range of “stakeholders,” Ramsey’s definition seems almost a truism from a policy standpoint.  Also, as I have heard Dr. Lee Newcomer of UnitedHealth recently put it, “we buy health insurance as consumers and use it as patients,” so the “consumer” perspective is unavoidable.  And on a bit of inspection, Ramsey’s definition is not all that far from Porter’s.  But I think I prefer Porter’s, if for no other reason than keeping the patient closer to the center.  Still, the very language of “value” may be but one more thing that threatens to lose a patient and her doctor in the crowd.

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Susan Haack
6 years ago

I find the terminology intriguing: “value,” which as you note is an economic term that is quantifiable–or potentially so–has replaced “quality,” a term that is subjective and in and of itself is not readily quantifiable. And yet as you imply,the economic term “value” conjures up the associated term, “values,” which creates ambiguity, as one confounds abstract principles and concrete calculations.

Secondly, the problem with Porter’s definition which you may have overlooked (or I might have looked at too closely, given the topic of my blog tomorrow) is that it in fact is not patient-centered at all (I am at a disadvantage in not having the entire quote). “Health outcomes” sounds suspiciously statistical–a reference to population health, not individual. This is I see it, and will share tomorrow, is one of the forces creating the paradigm shift in health care today–a shift in our horizon from the individual (and covenant relationship) to the population.