Comments on July’s Ethics Forum
Let me preface this by first applauding all of you for the creation of the ethics column and the selection of the first case, as it so adequately reflects the current socioeconomic climate within which we practice.
In regards to the case in which the patient stated that she could not afford the visit nor the labs required for her methotrexate to be refilled, I encounter this problem almost biweekly in our small Reno rheumatology practice. I first tell the patient why I can’t just prescribe the medicine. (Remember, most patients they think this simply entails the writing of a prescription without any liability or actual concern for patient safety.) After telling the patient what I can’t do, I then utilize a common strategy in customer service, which is to tell the patient what I can and am willing to do for him or her. I do ask that the patient be seen to discuss the matter further. If there is no insurance, a practice can offer a discount for not needing to bill the patient. This is not incongruent with commercial insurance or governmental program contracts, because your “discount” is not for the medical service, but rather for not having to bill the patient, provided they pay the discounted amount at the time of service. Of course, you must be willing to offer a similar discount to other patients in the same situation to avoid being accused of “unfair business practices.” This is not the same as discounting the fee for a patient with insurance, who has a large deductible or copayment, which would likely be a violation of the provider’s agreement with the insurer. Of course, each provider would have to verify individual state laws.
When I see the patient, I advise him or her of why I can’t simply provide the prescription. I am held to certain guidelines. These guidelines have been established to provide adequate patient safety. Good care is good care, regardless of ability to pay. However, there is a difference between “good” care and “ideal” care, and I am willing to provide “good” care if the patient is also willing to settle for this. I am not willing to provide “unsafe” care. If the patient suffers a complication, in this case due to methotrexate toxicity, I am not held to a lower standard of care because of the patient’s inability to pay. Of course, the patient will insist that he or she would never sue me, but I remind them that their loved ones or the state can sue me on their behalf, and I will have to live with the effects of my decision. My failure to follow minimum standards is not only malpractice, but unethical. It is one thing when a patient decides, after informed consent, to decline treatment because of the inability to afford such treatment, and the patient suffers a preventable complication as a result of omission of such treatment; it is another matter when the patient suffers a preventable complication as a result of a treatment which I helped by my provision of treatment.
I review the patient’s risk status and lab history, and will offer an acceptable minimum (e.g., a CBC and an ALT q4 months; office visits q6 months). I also advise patients of labs that offer special discounts and health fairs, and suggest ways to negotiate fees. Patients usually find this acceptable, because I am willing to work with them. I sleep better at night.
To agree to provide the prescription without following minimum guidelines suggests that such guidelines are in place only to support my income and the healthcare industry. What is unsafe is simply unsafe. How is it that something is only medically necessary if the patient is well insured? It either is or isn’t necessary.
I developed this gestalt after a situation when I was a hospital nurse. I had an elderly patient who had suffered a cerebrovascular accident and had significant dysphagia and was “Comfort measures only.” After an emotionally charged family meeting, the family determined that feeding her by mouth was nurturing and comforting and if she aspirated and died, this was acceptable since the intention of their actions was the provision of comfort. I, however, refused to be the person to feed her, but welcomed the family members to feed her. I did not want to be the person who performed the act that could result in her death. It was different for the family members to feed their own relative. However, if a registered nurse is feeding a patient, it is considered a nursing task. Would I have agreed to feed my own mother if I was sure that this is what she would have desired? Absolutely. But this was not my mother; this was a patient.
A similar scenario is encountered when a patient receives CPR, including intubation, only to have it discovered later that the patient had refused intubation in his or her living will. Not placing the tube is an act of omission; removing the tube is an act of commission. The end result is the same, yet in the first scenario, the provider has allowed the patient to die naturally; in the second scenario, the provider has removed life-sustaining treatment that was already in place, resulting in death. This is more difficult to consider.
Quite provocative!
Kimberley M. Morris, MSN, APN
Arthritis Specialists of Northern Nevada, Reno, NV
The Authors Respond
This is a thoughtful commentary on our inaugural column, which appeared in the July issue (p. 1) by Kimberley Morris of Reno, Nevada. Not only does she raise several interesting points concerning the case presentation, hers is the first response to the column and thus we thought it should be published in full.
Morris takes a somewhat different approach than we did. Employing a reasoned, well-argued position against the prescribing of medication in circumstances where appropriate follow-up is constrained, she develops her case utilizing a paradigm involving “good” versus “ideal” versus “unsafe” care, a reminder of the inherent medico-legal considerations, and presents a resolution that involves a sharing of responsibility across participants. We rather liked her analysis of the case, thinking perhaps it was better than ours.
C. Ronald MacKenzie, MD, Elizabeth Kitsis, MD, MBE,
and Michele Meltzer, MD, MBE
