You can scarcely open a newspaper or medical journal today without confronting a discussion pertaining to an issue involving medical ethics. Yet, despite the intense scrutiny of this subject from both inside and outside the medical profession, a recent paper published in Arthritis Care and Research (AC&R) pointed to a dearth of ethical discourse in the rheumatology literature.1,2 In order to explore the range of ethical challenges facing our professional community and discuss their implications, the ACR Committee on Ethics and Conflict of Interest is collaborating with The Rheumatologist to create a new feature called the “Ethics Forum.” This new quarterly department will foster dialog among rheumatologists and rheumatology health professionals concerning real life ethical issues that they may encounter in medical practice or research.
In each edition of the “Ethics Forum,” a member of the Committee on Ethics and Conflict of Interest will analyze brief clinical vignettes that illustrate ethical dilemmas arising from everyday practice. This discussion will concern the ethical principles involved and provide guidance for resolving the dilemma. The goal of these discussions is to be practical rather than theoretical. If you have an ethics question that you’ve encountered in practice, or if you have questions or comments about an “Ethics Forum” case, write us at [email protected]. We may publish your letter or question in a future “Ethics Forum.” We hope that you enjoy this first ethics case study—and that you write in with your own experiences or to ask a question for an issue that has challenged you.
The Case
You have been contacted by a pharmacy to renew methotrexate for a patient with longstanding rheumatoid arthritis. After realizing that she has not had lab monitoring or an office follow-up for a long time, the patient was contacted. The patient says that she is doing well on the methotrexate but has lost her health insurance coverage so she cannot afford office visits or laboratory studies. Despite a social work referral, the patient has been unable to get the lab test, or at least has not obtained a way of getting the lab testing performed. She says she knows and accepts the risks of taking methotrexate without monitoring and wants you to renew her medications until she obtains health insurance, at which time she will see you and have the testing done.
Ethical problem: What should a physician do when faced with an ethical problem that threatens to disrupt the planning or provision of care for a patient?
Discussion: This is a difficult—though perhaps not uncommon—problem, one without an entirely satisfactory solution from the physician’s perspective. How does one approach this situation?
The first step is to examine the patient’s medical condition in the context of such factors as the patient’s decision-making capacity, her preferences, and the role of other interests. In this case, these considerations seem relatively straightforward: a woman with longstanding rheumatoid arthritis is currently unable to afford office visits or cover the costs of standard laboratory monitoring due to the loss of her medical insurance. She has been able to afford her medication, which continues to control her disease without apparent toxicity.
The next step, which may be the most challenging, is framing the ethical problem. In this case, the dilemma speaks to your sense of medical professionalism. Should you continue to order a potentially toxic (though effective) medication in a patient who has not had a timely evaluation nor undergone the appropriate laboratory surveillance for relevant toxicities? If so, for how long? Yet, if you refuse, what will happen to the patient? Could such a decision be considered patient abandonment? Finally, put yourself in her shoes, with a chronic disease (that may in itself limit her insurance options), tolerating methotrexate with good effect. If she understands and is willing to take the risks of unmonitored therapy, isn’t she (and society, which may ultimately pay for her disability if she goes untreated) better off with her disease well controlled?
A third step in the process is to consider the role of other interests, in this case medical insurance. Indeed, it is the patient’s loss of medical insurance that sets the stage for the ethical dilemma. It is a circumstance over which you have no control, and for which you are not responsible. Medical insurance is a voluntary contractual agreement between two parties, usually mediated through the patient’s employer. While you could agree to see her without charging for the visit, the same may not be true of the payment for laboratory studies. You have already attempted to secure support for the patient through the social worker, although it is not clear that all available options for the provision of her care have been explored. For instance, could the local chapter of the Arthritis Foundation (or another charitable organization) be approached to provide financial assistance? Would the drug company provide the drug at no cost to the patient? Alternative medical care and insurance arrangements, such as an application for Medicaid, might also resolve this patient’s dilemma. Finally, there is the issue of personal responsibility. One needs to be careful not to “blame the patient,” but are you confident that the patient has been willing to make sacrifices in other life domains in order to find money to purchase the required medical care?
Recommendation: Ultimately, the least problematic of the less-than-desirable options may be to continue to follow her at arm’s length, providing the medication and thus maintaining control of her disease.
Final Note: Recalling the time-honored adage, “no good deed goes unpunished,” last year the State of Massachusetts adopted laboratory monitoring for patients receiving methotrexate as a major quality indicator by which they tier rheumatologists. In Massachusetts, you might need to find a different resolution to the clinical scenario. The moral of the story: Know your local regulations before you do the right thing.
Send us Your Case!
If you have comments or questions about this case, or if you have a case study that you want to see in Ethics Forum, e-mail us at: [email protected]
Dr. MacKenzie is associate professor of clinical medicine and public health at Weill Cornell Medical College, Hospital for Special Surgery in New York. Dr. Kitsis is director of Bioethics Education and a member of the rheumatology division at Albert Einstein College Medicine in the Bronx, N.Y. Dr. Meltzer is assistant professor of medicine at Thomas Jefferson University in Philadelphia.
