Ethics Forum: Has the Patient Asked for More Than Can Be Ethically Allowed?

The patient, a 76-year-old woman, had very active polyarticular rheumatoid arthritis (RA), despite triple therapy with conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs), low-dose corticosteroids and occasional intra-articular injections—the latter providing only transient symptomatic relief. She had elevated inflammatory markers and a 28-joint Disease Activity Score (DAS-28) score of 7.4. 

Because of the severity of her disease, the next appropriate step in management was the addition of a biologic agent. After discussing the options with the patient and her daughter, etanercept, a tumor necrosis factor α (TNFα) blocker, was recommended. The patient and her daughter agreed, and preliminary tests were ordered to determine if it could be used safely.

When the patient and her daughter returned to review the laboratory studies and discuss use of the agent, the patient’s daughter explained that the patient had an insurance plan with a substantial copay for biologic agents. The daughter requested that, instead, the prescription be written in her name; the daughter was well connected to the hospital and had a more robust prescription-reimbursement plan. 

The patient’s daughter was told this would not be possible, that there was no documentation that the daughter had rheumatoid arthritis—she had no preliminary laboratory studies—and that this would be fraudulent. Further, if by some chance the daughter were to take the medication on her own, adverse reactions might be possible from a medication neither indicated nor monitored. 

The patient and her daughter were adamant that they wanted in-home subcutaneous options rather than infusions at an infusion center, which would have been covered under the patient’s insurance. They were told the office could attempt to find out if the patient qualified for a manufacturer’s discount or financial support, but neither the patient nor her daughter found that acceptable and left without scheduling a follow-up appointment.

Discussion

As a practical matter, a biologic agent cannot be prescribed appropriately without an established indication and evidence of failure to respond to lesser treatments, as well as with initial and ongoing monitoring. These factors alone precluded acceding to the patient’s and daughter’s request. The explanation offered to them was non-accusatory; however, even if such a prescription were possible, the ethical implications would be substantial. 

Simply stated, medicine is a moral undertaking. As autonomous moral agents, patients have a right to competently accept or refuse diagnostic or therapeutic recommendations. That stated, the moral agency of physicians also must be respected. This means patients and their decision makers should not ask physicians to violate their conscience or the integrity of the profession. Engaging in a request to defraud a prescription reimbursement plan, even for the benefit of an underinsured patient, is beyond what should be asked or demanded.

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.

Richard L. Allman, MD, MS, FACP, FACR, was an associate director of the residency program in internal medicine at Einstein Medical Center, Philadelphia, from 2002–18. He has a Master of Science in Healthcare Ethics and continues to serve as the lead consultant in ethics at Einstein, while working part time to precept internal medicine residents.

References

1. Wynia MK, Cummins DS, VanGeest JB, Wilson IB. Physician manipulation of reimbursement rules for patients: Between a rock and a hard place. JAMA. 2000;283(14):1858–1865.
2. Freeman VG, Rathore SS, Weinfurt KP, Schulman KA, Sulmasy DP. Lying for patients: Physician deception of third-party payers. Arch Intern Med. 1999;159(19):2263–2270.

Editor’s note: This article was written for The Rheumatologist on behalf of the ACR Committee on Ethics & Conflict of Interest. If you have a comment for the author or a case you’d like to see in Ethics Forum, email us at [email protected].