Friday, January 2, 2009

Ethical Question? Or not?

Let's pretend you are a medical doctor, or dentist, or eye doctor.

A patient comes to you for an exam. The patient lost their health insurance when they lost their job two years ago. The patient is healthy and has been a patient of yours for several years, so you have access to medical history. They are strapped financially and cannot afford the full array of "tests" that you are recommending. These tests are "preventative" tests ie: if the patient is a woman, it's time for a mammogram....or maybe heart disease runs in the family, so you want to test for heart disease.

The patient says, "I understand the importance of the tests, but the reality is that I can't afford all of them. I can't afford X test, but I can afford Y test. Let's just do Y test."

As the patient's doctor, what do you do?

1.) Do you turn the patient away for ALL care until they agree to do all tests?
2.) Do you only do the tests that the patient can afford, thinking that SOME care is better than no care?
3.) Is this an ethical question or a financial question?
4.) Who has the right to determine the care that a patient receives? (Remember, insurance companies are not involved with this situation).

I know you will have more questions, but this is all the information you get. As the doctor, what would you do? I'll give you the full story tomorrow and tell you what actually happened. Because unfortunately, this is a real story.


allanjel said...

Hi I found your blog through a friend and it is really interesting. I am an EP in Cardiac/Pulm rehab and I have seen something similar.

IMO..I would give SOME care in hopes that it will help and try to educate the patient on the importance of getting in for more tests... Ethically, it is correct to run all the tests, but you are limited by the financial aspect and it is always a patient's choice as to what care they receive. Course ALL is MY OPINION :) It is a very tough situation for you.

Be back tomorrow to see the answer.

Bill said...

It is a tough situation for both the patient and the doctor. But I would believe from both points of view that some tests are better than none.

R. Jeffrey Davis said...

I would recommend to do at least some of the tests (assuming that this is a useful/helpful thing). It appears to me to be more of a financial issue rather than an ethical one (from my point of view given only the facts that you have revealed)

Jumper 2.0 said...

The answer is 2!

And 3 is both a financial and ethical question! Why does one exclude the other?

I don't know if the doctor can offer discounts. Does he own the clinic or is he part of an HMO etc?

I would also encourage X test at a separate time if it can be afforded due to not all of the bill being together (6 months later for example).

Runner Leana said...

So glad to see you are back with a new blog!

Geez, that's a tough question. Some tests are better than no tests I would think, but it is such a shame that you would have to choose.

knittingrunner said...

My answer is # 2. I had a doc tell me he was sure my achilles was torn but not ruptured so he would skip the MRI because of the expense. He was a triathlete himself and knew my goal was to run asap. He treated me for a torn achilles, ordered physical therapy and I was running 5 months later.

My daughter tore her achilles last January, had the MRI and ran in a triathlon in August. Did the MRI make a difference, I don't think so. We had the same treatment--and the same insurance, mine would have paid for the MRI but he didn't like to do unnecessary tests.

But health care is a mess in our country isn't it?

Kevin said...

Considering the patient is healthy, I would think #2 would be the right thing to do. Of course in the sue-happy society we live in, I could see a doctor possibly choosing #1 to cover his butt

Jason said...

Firstly, this post reminds me how good the health care system actually is in Australia, despite my complaints about. There is lot more funded through the government than in most other countries. Mainly it isn't linked to your job having health insurance. Better mention I work as paramedic too before answeing the questions.

I don't think you can separate ethics and finances, they are too intertwined. For example, if the doctor pays for the tests, or gets the money elsewhere will that take some level of care away from other patients? So it is both ethical and financial.

Who has the right to determine the care that a patient receives? In the end it is the patient. AUTONOMY is the fundamental principle of medical treatment. However, this is clouded by the need for informed consent. For the patient to make the best decision, they need to appropriately informed about their options. Therefore there is a duty of care from the doctor to do this.

In short, I believe the patient has the right to select which tests they have done. It is unfortunate that these tests will be limited by a financial situation. However, the doctor should help the patient decide which tests are more pertinent, ie. which gives them more bang for their buck... I know that's an uncomfortable phrase.

A blanket refusal from the doctor to do any tests, because the patient can't afford all of them I believe is innapropriate. Some care is better than none.