Purpose: We sought to determine if physicians’ personal moral intuitions were associated with their judgments about using cost-effectiveness data in clinical decisions as well as their judgments about cost-containment strategies.
Method: We surveyed 2000 practicing U.S. physicians regarding moral and social issues including their moral intuitions related to five constructs – harm, fairness, ingroup, authority, and purity. These constructs have been used in social psychology using a 6 point ordinal scale in a 30-item instrument with 5 subscales for each construct. We hypothesized that harm and fairness subscale ratings would be associated with favorable perceptions of using cost-effectiveness data and cost-containment strategies. We asked physicians to rate their degree of moral objection (none, moderate, or strong) to using cost-effectiveness data in clinical decisions. We then asked, on a 4-point scale, to what degree they agreed with limiting reimbursements for expensive drugs and procedures in order to expand coverage to uninsured patients (cost-containment). We used logistic regression to examine associations between harm and fairness subscale scores and judgments about cost-effectiveness and cost-containment (using dichotomized versions of these items).
Result: 1032 of 1895 physicians (54%) responded. In unadjusted analyses, harm ratings were significantly associated with moral objection to cost-effectiveness. For every 1-unit increase in harm subscale scores (0-5), there was a 20% greater chance of objecting to cost-effectiveness analysis in clinical practice (OR= 1.2 [1.0-1.4]). After adjusting for age, gender, region, and specialty, that association was no longer significant. Fairness scores were not associated with judgments about using cost-effectiveness data in clinical practice. Both harm and fairness were significantly associated with judgments about cost-containment. For every 1-unit increase in mean harm score, there was a 20% increased chance of agreeing with cost-containment (OR=1.2 [1.0-1.4]). Similarly, every 1-unit increase in mean fairness scores was associated with a 70% greater chance of agreeing with cost-containment. These associations were unchanged after adjusting for age, gender, region, and specialty. There was no association between ingroup, authority and purity and cost-effectiveness or cost-containment judgments.
Conclusion: Differences of opinion among U.S. physicians related to cost-effectiveness data and cost-containment measures may arise from differences in the relative importance they place on key moral intuitions. Efforts to enlist the support of physicians in cost-containment may need to account for this diversity of moral intuitions.