Medical Overtreatment in the United States: Causes, Consequences, and Solutions

Abstract

Healthcare practitioners have a responsibility to adhere to ethical guidelines during all medical procedures. But in certain cases, these guidelines are breached. Medical overtreatment is such a case. The phenomenon of overtreatment operates in discordance with the four main bioethical principles of beneficence, non-maleficence, autonomy, and justice/equity. The over-provision of medical treatment has peaked in recent years due to the combination of technological advancements, public beliefs, and financial incentives. From the patient’s perspective, the cost is high: physical iatrogenesis—injuries obtained through medical care— and excessive expense on medications and procedures that are unnecessary. To reduce the overuse of medical resources, solutions like reducing incentivized systems, amending the liability system, and enlightening medical students should be implemented. Most importantly, the healthcare system should explicitly stress the importance of granting patient autonomy through communication. This study examines how ethical issues underlie overtreatment in the United States an provides an instructive framework to examine causes, effects, and solutions of medical overtreatment. 

Introduction

In the 21^st century, as medical improvements spanning from novel drug development, to improved screening methods, to diagnostic testing have emerged, a novel ‘epidemic’ has steadily risen in prominence — overtreatment. Overtreatment refers to the prescription of unnecessary treatments and medications by physicians to patients with little evidence of benefit – or worse yet, prescribing medical interventions that inflict bodily harm (Carter & Barratt, 2017). As opportunities to use new technologies have increased, so have the numbers of therapeutics and medications. However, the public should recognize that use of additional medicines do not necessarily lead to increased physical health and psychological well-being; rather, increased drug use may impede good health. In the United States, one recent online survey sent to American Medical Association physicians revealed that the majority of those asked estimated 15 to 30% of their fellow doctors overtreated their patients (Lyu et al., 2017). Reported percentages of overtreatment in Madhya Pradesh, a rural city of India, were even higher – according to one study, 41.7% of sampled physicians prescribed unnecessary treatment to standardized patients (patients trained and rehearsed to enter doctors’ offices and demonstrate particular symptoms), signifying the relevance of the issue in both developed and developing regions (Das et al., 2012).

Overdiagnosis is often stated as the cause of overtreatment. Overdiagnosis refers to the (mis)diangosis of a medical condition that is, in fact, not harmful to an individual’s ordinary lifestyle (InformedHealth.org, 2017). Overtreatment follows early and unnecessary diagnoses, and complicates the ethical duties of physicians.

What are these ethical duties? The basic principles of medical ethics are  beneficence, non-maleficence, justice, and autonomy. Together they define the fundamental needs that doctors need to maintain as they provide care (Varkey, 2020). All four aspects are violated by overtreatment. One major challenge of medical treatment from an ethical standpoint is that not all members of the public, and even of the medical field, agree on what is improper. Whereas some may claim that certain procedures are morally right, others may claim them too harmful (or not helpful enough) and too costly to be justified. It is necessary to be cognizant of the viewpoints of all parties before rendering a verdict on what is proper and what it not. It is only after such an analysis that when we can arrive at a proposal to combat overtreatment ; one that reflects the spirit of Euripides,  “Not too little, not too much: there safety lies.”

Medical Ethics and the Underlying Causes of Overtreatment

From a bioethical perspective, overtreatment has long been a major point of discussion. One could say that the most important parts of medical care are the physiological result of patient rehabilitation or the diagnosis of the true cause. In achieving these goals, the physician should act out of beneficence — the moral duty to provide positive outcomes to the best of one’s abilities (Varkey, 2020). Of equal importance is the creed of doing no harm, or non-maleficence. On top of these two standards, it is increasingly recognized that physicians ought to maximize patient autonomy. Autonomy, as defined in medical ethics, refers to the self-governance or self-control of patients in their responsibility of taking medications, receiving treatment, and receiving diagnostic tests (Varkey, 2020). In healthcare, autonomy is limited without knowledge. Without sufficient knowledge, patients hold misconceptions or may be subject to purposeful disinformation from physicians with financial pursuits in mind (Varkey, 2020). Thus, patient autonomy rests on the principles of justice and equity, which dictate that the public have broad and equal access to information and resources (Varkey, 2020).

Why is overtreatment so prevalent in the US medical system? One can start by asking doctors themselves.  In 2017, an online survey was sent out to doctors from the American Medical Association, collecting opinions about the extent of the overutilization of medical resources and its possible causes (Lyu et al., 2017). The majority of respondents (84.7%) ascribed the reason for overtreatment to a fear of malpractice if treatment was to be found lacking, while 59.0% replied “patient pressure/request” as the cause (Lyu et al., 2017). Although only 2-3% of patients who claim to have received negligent care seek litigation, fears of medical claims are still very common among doctors, particularly since one lawsuit can profoundly damage their reputation and risk their license to practice medicine being stripped (Bell et al., 2012).

The liability system of the United States is managed primarily by state courts, rather than the federal government (Bal, 2008). Therefore, the decisions vary from state to state, but studies have found malpractice lawsuits to be relatively common in the United States in comparison to other Common Law countries (Ross, 1977). To be held accountable for an injury, the patient must prove that the fault was due to the negligence of the physician without their own intervention (Bal, 2008). If the physician is proved to be at fault, they need to provide monetary compensation to the patient, which includes recouping economic losses from the injury, the costs of future medical care, and the costs of non-economic adversities such as mental suffering or trauma (Bal, 2008). Regardless of the outcome, the preparation for jurisdiction trials itself takes substantial time, resources, and money (Bal, 2008). On average, the plaintiff and defending clinician spend more than $100,000 on the preparation of medical negligence lawsuits alone (Bal, 2008). Such preparation often includes hours of conversations with the attorney, interviews, reviews of records, and appraisal of legal conventions (Bal, 2008). Thus, there is undeniable anxiety that accompanies the cumbersome procedures of lawsuits, whether the physician was at fault or not. Another motivation for overtreatment may stem from the fear of harm; endangering a life due to undertreatment brings a hefty psychological cost for doctors who are passionate about the health and satisfaction of patients.  

The remarkable percentage of physicians who stated “patient pressure/request” as their reason for overtreatment demonstrates the unfortunate and commonplace communication barriers which exist between patients and their caregivers. The public may assume that more tests and screenings lead to better care, which puts pressure on doctors to provide additional medications lest they risk dissatisfaction with their hospital (Lyu et al., 2017). The term “patient pressure/request” may actually illustrate the lack of communication and thus lack of patient autonomy. A survey reported that 89% of doctors thought “patient experience” was a critical factor of quality care and of significance, but only 16% affirmed that they ask patients their expectations (Rozenblum et al., 2011). These statistics determine the lack of patient self-governance, as doctors who do not acknowledge patient expectations are likely to give treatments that are not consistent with the patient’s preferences. Physicians need to acknowledge that valuing patient autonomy and communication is correlated to better patient experience and health outcomes, as well as fewer lawsuits and greater patient satisfaction (Chandra et al., 2018).

Overtreatment and Overdiagnosis: Benefits and Drawbacks  

Medical radiation (from CT scans, X-rays, radiotherapy, etc.) is the largest man-made source of radiation today (World Health Organization, 2016). Notably, the United States recorded an average medical-induced radiation exposure five times the global average between 2009 and 2010 (World Health Organization, 2016). The country’s rapid technological advancements have led to numerous applications of radiation, from radiopharmaceutical treatments to medical imaging. Among medical imaging techniques, CT scans and nuclear imaging both use significant radiation doses (De Gonzalez, 2011).