What’s in a word so often depends on its context, so imagine how much fun you can have introducing a contentious word into the roiling world of health care.
The longer the word is the better, because it turns out that words with few letters have the most definitions. The winner in this regard is ‘set,’ for which the Oxford English Dictionary reports 464 different definitions. (Ironically, not a whole lot is actually set about this word until it has a setting.) Second place for the most definitions is ‘run’ (396), while third goes to ‘go’ (368). But a longer word may be about to go on a roll. On January 3 ‘parsimonious’ was incorporated into an update of the American College of Physicians (ACP) Ethics Manual and suddenly all hell is breaking loose.
Here’s how to create an etymological and philosophical stir in four easy steps.
- Be sure that you have 132,000 physician members and that you’ve built a solid reputation for producing one of the “definitive statement[s] of medical ethics.”
- Include the following in the aforementioned definitive manual, using a word synonymous with being frugal and stingy – a word that might easily describe a Dickensian character. Make sure that it taps into a fundamental health care system tension thusly:
“Physicians have a responsibility to practice effective and efﬁcient health care and to use health care resources responsibly. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient respects the need to use resources wisely…”
- Make sure nobody misses the update by composing an accompanying editorial calling the change remarkable because the manual is now “advocating the principle of cost-effectiveness” – even if one of your own people admits that the word parsimonious has been in the manual since 1984. Timing and positioning are everything folks.
- Enjoy the show.
In just two weeks Kaiser Health News, AARP, NPR, Medscape and the blogosphere have fueled debate and discussion, with numerous other sites linking to them. Given the rate and breadth of interpretation in just 14 or so days, ‘parsimonious care’ could give ‘set’ a run for its money by the end of 2012.
On balance, most are expressing that the ethics manual revision is a good thing, with some questions and caveats. However, those who have issues tend to be significantly worried, voicing something along these lines.
“It’s really the word ‘parsimonious.’ If there’s a problem in their statement, that’s it. Of course we need to be efficient, of course we need to be conscientious. The word itself carries a connotation that is going to give people pause if it’s a precursor to rationing.” – Rep. Michael C. Burgess, R-Texas, Member of Congress; physician (source: Kaiser Health News)
“[It] really implies that care should be withheld. There’s no definition of parsimonious that I know of that doesn’t imply some kind of negative connotation in terms of being stingy about how you allocate something.” Dr. Scott Gottlieb, the American Enterprise Institute (source: NPR)
Things likely won’t turn out well for parsimonious. Most likely, the ‘p’ word will become a close cousin of the ‘r’ word, a.k.a. rationing. It doesn’t have to be this way. Another word need not be trampled in the court of public opinion. We could theoretically run short of them over time, and actually be forced to ration their utilization in the future. We may need Arthur Caplan to step in – as he did here in 2009 with ‘allocation’ and ‘rationing’ – and reclaim parsimonious care before things go too far.
There is an alternate future path for 2012. Rather than debating a word/phrase until one group goes numb and surrenders, we could all just come to our senses, stop parsing phrases or debating semantics and get on with the real work of changing our approach to resource allocation (the first and best option) and rationing (when resources are scarce) while maintaining focus on the higher goal of providing care that does no harm either to the patient or to the patient’s context for living, a.k.a. our society.
We may be either amused or annoyed that this much energy has been devoted to a word when words aren’t really the point or the problem. The debate is likely to continue, and that could be either a good or bad thing. If we work at it, we can get what we need from this stir: a frank, reasoned discussion of what health care can and should do. When to start, how long and how far to go with treatment and when to stop will never be reduced to a handy, easy-to-use flowchart. Any decision involving the well-being of fellow human beings is a distinctly situational and difficult one to make. Yet make them we do. Everyday. Even when we believe that we are sidestepping them. As the great philosopher Neil Peart notes, “if you choose not to decide, you still have made a choice.”
Rather than discuss words, we should conscientiously word a discussion that yields alignment on a path to something better. Rather than fearing rationing, we should work to be compassionate and rational in our approach to health care. Rather than worry about what it means to be parsimonious, we should worry about what it means to be human.