Antiel Ryan M, Curlin Farr A, James Katherine M, Tilburt Jon C
Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA.
Philos Ethics Humanit Med. 2013 Sep 8;8:13. doi: 10.1186/1747-5341-8-13.
Physicians vary in their moral judgments about health care costs. Social intuitionism posits that moral judgments arise from gut instincts, called "moral foundations." The objective of this study was to determine if "harm" and "fairness" intuitions can explain physicians' judgments about cost-containment in U.S. health care and using cost-effectiveness data in practice, as well as the relative importance of those intuitions compared to "purity", "authority" and "ingroup" in cost-related judgments.
We mailed an 8-page survey to a random sample of 2000 practicing U.S. physicians. The survey included the MFQ30 and items assessing agreement/disagreement with cost-containment and degree of objection to using cost-effectiveness data to guide care. We used t-tests for pairwise subscale mean comparisons and logistic regression to assess associations with agreement with cost-containment and objection to using cost-effectiveness analysis to guide care.
1032 of 1895 physicians (54%) responded. Most (67%) supported cost-containment, while 54% expressed a strong or moderate objection to the use of cost-effectiveness data in clinical decisions. Physicians who strongly objected to the use of cost-effectiveness data had similar scores in all five of the foundations (all p-values > 0.05). Agreement with cost-containment was associated with higher mean "harm" (3.6) and "fairness" (3.5) intuitions compared to "in-group" (2.8), "authority" (3.0), and "purity" (2.4) (p < 0.05). In multivariate models adjusted for age, sex, region, and specialty, both "harm" and "fairness" were significantly associated with judgments about cost-containment (OR = 1.2 [1.0-1.5]; OR = 1.7 [1.4-2.1], respectively) but were not associated with degree of objection to cost-effectiveness (OR = 1.2 [1.0-1.4]; OR = 0.9 [0.7-1.0]).
Moral intuitions shed light on variation in physician judgments about cost issues in health care.
医生在对医疗成本的道德判断上存在差异。社会直觉主义认为，道德判断源于直觉本能，即所谓的“道德基础”。本研究的目的是确定“伤害”和“公平”直觉能否解释医生对美国医疗保健中成本控制的判断，以及在实践中使用成本效益数据的情况，同时确定这些直觉在与成本相关的判断中相对于“纯洁性”、“权威性”和“内群体”的相对重要性。
我们向2000名美国执业医生的随机样本邮寄了一份8页的调查问卷。该调查包括MFQ30以及评估对成本控制的同意/不同意程度和对使用成本效益数据指导治疗的反对程度的项目。我们使用t检验进行成对子量表均值比较，并使用逻辑回归来评估与成本控制同意度和使用成本效益分析指导治疗的反对度的关联。
1895名医生中有1032名（54%）做出了回应。大多数人（67%）支持成本控制，而54%的人对在临床决策中使用成本效益数据表示强烈或中度反对。强烈反对使用成本效益数据的医生在所有五个基础上的得分相似（所有p值>0.05）。与“内群体”（2.8）、“权威性”（3.0）和“纯洁性”（2.4）相比，对成本控制的同意与更高的平均“伤害”（3.6）和“公平”（3.5）直觉相关（p<0.05）。在根据年龄、性别、地区和专业进行调整的多变量模型中，“伤害”和“公平”均与成本控制判断显著相关（OR分别为1.2[1.0 - 1.5]；OR为1.7[1.4 - 2.1]），但与对成本效益的反对程度无关（OR为1.2[1.0 - 1.4]；OR为0.9[0.7 - 1.0]）。
道德直觉有助于解释医生对医疗保健成本问题判断的差异。
