The moral psychology of rationing among physicians: The role of harm and fairness intuitions in physician objections to cost-effectiveness and cost-containment

Abstract

Introduction: 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.Methods: 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.Results: 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]). Conclusions: Moral intuitions shed light on variation in physician judgments about cost issues in health care. © 2013 Antiel et al.; licensee BioMed Central Ltd.