Calling for an “unwavering focus on the primacy of patient welfare,” a pair of medical ethics scholars urges careful consideration of how the concept of high-value care (HVC) should be integrated in medical education.


The JAMA Viewpoint published December 6 states, “if primacy of patient welfare is to truly remain fundamental to the profession, instilling commitment to this principle should be the most critical ethical value instilled in cultivating professional identity.”


If ‘value’ is considered the ratio of health benefits achieved per unit of cost, value can be increased in several ways: increasing health benefits, decreasing costs, or accepting less health benefit as a trade-off for cost savings.


Teaching approaches that over-emphasize cost savings “could risk causing trainees to lose sight of individual patient welfare or create unintended consequences for subsequent bedside decision-making,” write Viewpoint authors Matthew DeCamp, MD, PhD, and Kevin Riggs MD, MPH


“Physicians must sometimes balance ethical tension between cost-saving and patient welfare. The best way to do this is unsettled among ethics scholars and practicing physicians. This lack of consensus could lead to inexperienced medical trainees misunderstanding their duty,” says DeCamp, assistant professor at the Johns Hopkins Berman Institute of Bioethics and Division of General Internal Medicine.


The consequences could be damaging to both the physician-patient relationship and the profession, the authors say. “[A]mbiguity regarding the primacy of patient welfare in HVC education risks patient distrust and societal backlash against what might be perceived as training future physicians to control costs at the expense of patient welfare.”


The authors do believe that the concept of value can be ethically introduced in medical education, but the distinct perspectives of patients, organizations and society must be included, and how value is taught may need to be tailored to medical trainees’ level of experience.


“Early on, it may be more appropriate to focus on teaching medical students to communicate about costs with patients.  Later, more complex concepts of value could be introduced, DeCamp says. “This is much the same way we teach in other areas of medicine – blood draws first, heart catheterizations later.”


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JAMA Viewpoint: “Navigating Ethical Tensions in High-Value Care Education” Matthew Decamp & Kevin Riggs, JAMA. 2016;316(21):2189-2190. doi:10.1001/jama.2016.17488


Dr. Riggs’ work on this manuscript was supported by National Institutes of Health grant T32HL00718


About the Johns Hopkins Berman Institute of Bioethics
One of the largest bioethics centers in the world, the Johns Hopkins Berman Institute of Bioethics is the home for collaborative scholarship and teaching on the ethics of clinical practice, public health and biomedical science at Johns Hopkins University. Since 1995, the Institute has worked with governmental agencies, nongovernmental and private sector organizations to address and resolve ethical issues. Institute faculty members represent diverse disciplines including medicine, nursing, law, philosophy, public health and the social sciences. More information is available at

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