Ethical Challenges Come Home

Abstract

The patient-centered medical home (PCMH) is becoming a Rashomon-like touchstone for how health system reforms are expected to affect primary care. While PCMH pilot programs nationwide are serving as test cases for how reforms might play out, primary care advocates also tend (a) to see in them the ideals we want to see, and (b) to not see some ways they might challenge us.1 In a position paper in this month’s Journal,2 the American College of Physicians (ACP) Professionalism, Ethics and Human Rights Committee begins to address these issues, opening a crucial conversation by asking the question: Does the PCMH promote Beauchamp and Childress’ four core principles of medical ethics (namely: respect for autonomy, beneficence, nonmaleficence and justice)?3 To answer this question, the Committee compared the Joint Principles of the Patient Centered Medical Home, developed by the ACP and several other primary care-oriented specialty groups,4 and a similar set of “key attributes” of patient-centered primary care, with the four principles of medical ethics. Their answer is a qualified, but still loud, “Yes!” In particular, they note that patient engagement in care decisions and patient-centeredness more generally (two sine qua non features of an ideal PCMH) are directly supportive of autonomy, beneficence and nonmaleficence. A third PCMH feature, access to a personal physician, is seen as supporting the ethical requirement that physicians seek to ensure access to care for all, a derivative of the principle of justice. Finally, the PCMH focus on systematic efforts to improve safety and quality is recognized as supporting nonmaleficence and beneficence. It is not surprising that the authors conclude the PCMH is largely consistent with Beauchamp and Childress’ four principles. After all, the Joint Principles read very much like a list of general principles for excellent medical practice—medical care in any setting is better when it is patient-centered, safe, easy to access, engages patients in care decisions, exchanges information readily, continuously improves quality, and so on. So the PCMH, as a concept defined by these aspirational principles, is bound to support the traditional four principles of biomedical ethics. We propose to extend the Committee’s analysis in two ways. First, the rubber hits the road when broad principles are used to guide practical decisions. There are ethical implications in defining what comprises a PCMH, measuring its success, and paying for its implementation. Second, ethical analyses based on principlism don’t always force us to ask the toughest questions about our own contributions to ethical problems. Specifically, as Arend et al. have noted, the transformation to PCMH practice forces physicians to develop “new mental models of patient care.”5 Our own willingness to accept the deeply challenging implications of adopting PCMH ideals in our professional lives might prove the highest hurdle of all.