This case illustrates the obstacles that underinsured patients confront, but the solution the patient and her daughter suggested was ethically indefensible.
Access to needed care and disparities in coverage are broad societal problems that demand the attention of ethical practitioners. The moral obligation for medicine as an organized moral community is to advocate for access to needed treatments for all our patients, both individually and collectively through our professional societies, and to explore options either through alternate insurers or through manufacturers’ support programs, while preserving the honor of the profession as adhering to the highest ethical standards.
Some literature addresses the unsettled ethical landscape of “gaming the system” by altering assessments of disease severity to obtain third-party approval for beneficial interventions or changing the primary diagnosis for similar diagnostic and therapeutic benefits, practices that have have collectively been described as covert advocacy.1
Gaming the system is well intentioned for the patient’s benefit, but ethically dubious. It entails deliberately misrepresenting a diagnosis or severity of illness to obtain reimbursement for a service that has medical benefit but is not covered by a patient’s particular insurance contract.
All physicians likely have encountered patient requests for what seem like excessively long periods of disability from work, or requests for in-home services, which, while convenient, are not truly medically necessary, and requests for marginally necessary durable medical equipment, all of which skirt the edges of truthful documentation. Physicians have significant obligations to their patients: to be competent; to act in the interest of their patients, including through private and public advocacy; and to undertake acceptable risks for the benefit of their patients, the latter of which we have encountered during the long season of COVID-19. Nonetheless, there is no moral obligation to compromise our character or integrity, even in situations of regrettable denial of valuable service or medications.
Freeman et al. articulated concern about physician complicity with deliberate deception, including legal, contractual and ethical consequences:
Situations that produce deception can ultimately only be solved by direct confrontation and frank dialogue between physicians, patients and payers. Alternatives to deception include broadening existing appeals processes on behalf of individual patients and political advocacy for health care reform. Refusal to initiate a social dialogue regarding the appropriate balance between medical and economic considerations places medicine at risk of becoming a practice of equal parts patient care and subterfuge.2
The case described is far beyond the bounds of gaming the system, but is a clear request for falsification of diagnosis to which the patient or her daughter have no moral standing to request the physician’s complicity, and the physician is morally obligated to respectfully refuse.
