Is it ethical to perform a service for someone without a good faith estimate of what you’re going to charge them? Would you let a mechanic make major modifications to your car without having the mechanic explain how those changes could negatively impact your driving experience or your car’s reliability? Perhaps — many modifications of this type are purely for enthusiasts, and they probably know all about the risks involved. But can you imagine letting a mechanic start modding your car without a price estimate? Unless your name is Bezos or Croesus, probably not.
Asymmetrical information is what happens when one party to a deal has more information than the other. Since money is perfectly fungible — that is, one dollar is worth exactly the same as another — the seller or service provider in any given transaction usually knows exactly what she’s getting. The buyer, on the other hand, is usually receiving a good or service he doesn’t fully understand. Since the seller has access to the goods, or expertise in the services, she may have a duty to disclose certain information to the buyer. This could be anything from a retailer marking an item as a “second” if it has a cosmetic defect, to an attorney explaining the risks inherent in a particular trial strategy.
The medical field has wrapped this concept into a doctor’s ethical duty to his patients: he must provide them with enough information for them to make an informed choice regarding their medical care. A doctor can only proceed with non-emergency treatment after receiving a patient’s “informed consent,” that is, the patient agrees to proceed after the risks have been explained. A general practitioner shouldn’t prescribe a medicine without talking to you about the possible side effects. A surgeon certainly can’t operate on you without describing the risks involved. But currently, the cost of treatment is not part of the information required for a patient to consent to treatment.
The core principle behind informed consent is that people are autonomous beings. Recognizing the dignity of another person requires allowing them to make important decisions for themselves. Since most people have not gone to medical school, doctors are better positioned than their patients to understand these risks. But only the patient is able to properly weigh those risks and rewards in their own life. So, it is incumbent on the doctor to provide the patient with enough information about the risks and rewards of a particular treatment, as well as potential alternatives. Only then can a patient make an informed decision.
A doctor might expect someone who consents to surgery on their right hand to mitigate pain would also consent for the same type of procedure on their left hand. But if the person is left-handed, they may judge that the chronic pain is less trouble than the temporary loss of use of their dominant hand. A singer may be unwilling to have surgery that could potentially impact their vocal cords, where a construction worker would be less concerned. Situations like this are why patients get to make those decisions in all but the direst circumstances.
Just as a patient is the only one who can weigh the medical risks against his personal situation, only the patient is qualified to weigh the financial costs of medical care against the likely benefits. And just as the doctor is the person best positioned to convey the medical risks, someone on a doctor’s staff is best positioned to convey price information to the patient. After all, the service provider sets the pricing, don’t they? If they contract with a third-party insurer, that arrangement is supposed to be for the benefit of the patient. Surely the service provider can figure out how much the patient will owe prior to providing the service.
But currently, most doctors and hospitals do not recognize an ethical duty to give their patients this good faith estimate of their out-of-pocket expenses. The legislature is currently considering a bill that would force healthcare facilities to give an up-front estimate if they are going to use collections. This would be a good policy. It ought to be unnecessary. The ethical depravity of giving someone the runaround before a procedure and then sending them multiple bills after the fact ought to make every doctor’s skin crawl. What happened to “do no harm”?
Informed consent should include price as a matter of course. Currently, the courts interpret informed consent as a common law theory, meaning they could add price to its definition. The legislature always has the power to codify such a definition in statute — this is probably the best way forward, since it affords doctors notice that they will be accountable for providing the price information. The legislature and the courts each have at their disposal the means to correct this glaring omission in the medical ethical code. Or doctors could correct it themselves. They could insist that their patients not be blindsided by surprise billing. It’s the right thing to do, and it’s the only way the medical profession can do no harm.
The opinions expressed in this blog are those of the author, and do not necessarily reflect the official position of 1889 Institute.