Chapter 17: A Claim of a Right to Health Care

Section 5. Decision Scenarios

Summary of Methodology for Analyzing and resolving Cases involving moral dilemmas in Health Care:

Methodology: http://depts.washington.edu/bioethx/tools/cesumm.html

Paradigm for the Method:  http://depts.washington.edu/bioethx/tools/4boxes.html

Sample Case Analysis: http://depts.washington.edu/bioethx/tools/cecase.html

Introduction to Clinical Ethics, 4th edition using the case of Dax Cowart.:

http://depts.washington.edu/bioethx/tools/ceintro.html

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SCENARIOS:

For each of the scenarios you should consider how a person would reach a decision if that person were using the basic principles from EACH of the following traditions:

  • EGOISM

  • UTILITARIANISM

  • NATURAL LAW THEORY

  • KANT's CATEGORICAL IMPERATIVE

  • RAWLS MAXI_MIN PRINCIPLE of JUSTICE as FAIRNESS

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DECISION SCENARIOS:

1. Lack of Health Care coverage for children of workers

2. Health Care coverage for only the least expensive treatment options

3.Self Employed and self Insured and Unable to pay for expensive treatments

4. Underinsured

5.Rationing and priorities for procedures

6.Custodial Care: Self imposed poverty- pauperization to qualify for state provided care

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Decision Scenario 1

                “You need to bring Time back in about two weeks and let me have another look at him, “ Dr. Jane Mallory said,  “I suspect he’s got a form of inflammatory bowel disease, and I want to see how he does with the drugs and diet.  I Few can’t get the disease under control, he might have to have surgery.”

                “I’m sorry, Doctor,” Mr. Hinshaw said.  “I just don’t have the money.  My insurance policy at work covers me, but my wife and kids aren’t covered.”

 

From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 861, Decision Scenario 2

 

“We can offer you a couple of options,” Dr. Kenton said.  “Whatever will make the pain stay away,” Bill Czahz said.

“We can do coronary artery-bypass surgery.  Two arteries are involved, so for you it would be a double bypass.” 

“This isn’t something experimental?”
”No, it’s a well-established procedure with a good safety record.  About eighty percent who have

surgery get rid of their angina.”  

                “I don’t much like the idea of being cut, but I’d do most anything to stop those chest pains.”
                “The other option is that we can treat you medically.  We can try you on some drugs and see how you do, put you on a diet, and keep a close watch on you.  People we treat this way do a little bit better in terms of living longer than those treated surgically.  That’s a little misleading, though, because those who have surgery usually have worse cases of the disease.”

                “What about the angina pains?” Mr. Czahz asked. 

                “There’s the problem.  Medical treatment can do something about th pains, but it’s really not as effective as surgery.”

                “So I’ll take the surgery.”
                “Aren’t you on health stamps?” Dr. Kenton asked.

                “That’s right.”
                “We’ve got a problem then.  You see, health stamps won’t cover the cost of bypass surgery.  It’s an optional procedure under the HHS guidelines, and they won’t kick in the extra money to pay for it.”

                “So I have to make up the difference myself?”
                “That’s right,” Dr. Kenton said.  “You’re going to have to come up with about five thousand in cash.”

                “Dr. Kenton, there’s no way I can do that.”

                “Okay, then.  I just wanted you to know what the possibilities were.  We can put you on a treatment program, and I’m sure you’ll do just fine.”

                “But what about the angina pain?”
                “We’ll do what we can,” Dr. Kenton said.

 

From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 861-862, Decision Scenario 3

 

                The cashier’s office of Archway Memorial Hospital is, even for the wealthy and best educated, a place of frustration. Bills are presented in the form of long computer printouts, covered with unfamiliar names referring to supplies, medical treatment, and diagnostic tests.  Associated with each item is a price that seem absurdly high. 

                For someone without medical insurance, being faced with such a bill is more than confusing—it’s frightening.  And that was just the situation that Marvin Baldesi found himself in.

                “Your age make you ineligible for Medicare,” said Ms. Kearney, the Archway billing officer.  “And you say you aren’t covered by a private insurance plan?”
                “That’s right,” said Mr. Baldesi.  “I own my own business.  My wife and me, we run a small upholstery shop.  We decided we couldn’t afford to keep up our insurance.”

                “ Normally, we wouldn’t have admitted you,” said Ms. Kearney.  “It’s only because you came in as an acute emergency that you were allowed to run up such a bill.”  She paused.  “You’re going to need some follow-up treatments, too.”

                Mr. Baldesi looked down to keep from meeting Ms. Kearney’s eyes.  He felt embarrassed.  He had always paid his bills, and now this woman didn’t bother to disguise the fact that she saw him as a deadbeat. 

                “Do you have any savings?” Ms. Kearny asked. 

                “About fifty dollars.  Just enough to keep the account open.:
                “Then it looks to me like you’ve only got two choices,” Ms. Kearney said.  “You’ve got to borrow the money or declare yourself bankrupt.  If you do that, once you’ve exhausted your assets, you’ll be eligible for Medicaid.”

                “But the bill is almost fifty thousand dollars,” Mr. Baldesi said.  “I can’t borrow money like that.  My family and friends don’t have it, and no bank would loan it to me without collateral.”

                “Then you’ll have to get a lawyer and declare bankruptcy.”
                “But I’ll lose my business.  My credit will be ruined, and I won’t be able to get the materials I need from suppliers.  Isn’t there any other way?”

                “I don’t know any,” said Ms. Kearney.  “But that’s not really my problem.  But Archway has to be paid.  You received our services, and we have to have the money for them.”

 

From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 862-863, Decision Scenario 4

 

                When the pain began, Alan Warfard was certain he was having a heart attack.  The pain lasted more than an hour, and when it was finally over he was weak and exhausted.  He knew there was something seriously wrong with him, and as soon as he was able, he called his next-door neighbor and asked her to drive him to Southwest Hospital.

                “You have no insurance coverage, except for Medicare?” the man at the admitting desk asked Mr. Warfard.  “No private insurance at all?”
                “Just Medicare,” Mr. Warfard said.

                “Can you show us any financial records, such as savings-account passbooks, to establish that you are able to pay your charges here?”

                “I live on my Social Security check, and I don’t have a savings account.”

                “Do you have any relatives willing to sign a statement assuming financial responsibility for your treatment here?”

                “I’m afraid not,” Mr. Warfard said.  “But I don’t see what the problem is.  I told you—I’m covered by Medicare.  Isn’t that enough?”

                The admitting clerk shook his head.  “I’m afraid it’s not.  We don’t know what your treatment is likely to cost, and we don’t know whether Medicare would pay for all of it.  You know, they pay only a certain amount, and you might run up bills about that.  This is a private hospital, and I’m afraid that, without your being able to guarantee that you can pay us, I can’t admit you for treatment.”

                “But I’m sick,” Mr. Warfard said.  “What am I supposed to do, just go home and die?”
                “That’s not really our concern,” the clerk said.  “But I suggest you see if you can get yourself admitted to a public hospital.  Taking care of people like you is their responsibility.”

                The phrase “people like you” stung Mr. Warfard’s pride.  After all those years of paying his taxes and being a good citizen, how could he be dismissed so easily?

 

From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 863, Decision Scenario 5

 

                “Let me see if I understand you correctly,” Mrs. Burgone said.   “I need a liver transplant, but I’m not allowed to have such an operation?”

                “That’s correct,” Dr. Popp said.  “The National Health policy stipulates that transplant surgery cannot be performed on patients over the age of seventy.”

                Mrs. Burgone shook her head.  “But I don’t expect National Health to pay for it.  I’m able to pay for it myself.”

                “That doesn’t matter.  It’s a matter of social policy, not medicine.  The idea is that we can’t afford, as a society, to do everything for every patient.  You might be able to pay for such an operation, but not everybody can.  Then society would have to pay for those who can’t afford it, and society can’t afford to do that.  Consequently, to be fair, the operation is denied to everyone above the age of seventy.”
                “That doesn’t seem fair to me,” Mrs. Burgone said.  “How can it be fair to condemn someone to pain and greater risk of death when a way of changing this is available?”

 

From:  Munson, Ronald. INTERVENTION AND REFLECTION.6th ED.,Belmont, California: Wadsworth Publishing Company,2000  ., Page 863, Decision Scenario 6

 

                “Let me explain it to you, Mr. Faust,” Charles Young said.  “Although your wife is covered by Medicare, we cannot pay for the care she is receiving in the nursing home.  As an Alzheimer’s patient, she’s getting custodial care, and that is explicitly excluded from Medicare coverage. Do you have any insurance?”

                “My wife and I both have coverage through my job.  Bu the benefits office told me exactly the same thing.  My policy doesn’t cover long-term, chronic, or custodial care.”

                “I’m sorry to hear that,” Young said. “That means that you’ll have to pay the total cost of care yourself.”

                “Where can a sales rep get that kind of money?” Mr. Faust said.  “A nursing home will cost me forty or fifty thousand dollars a year.  If I sell our house and use all our savings, I could pay for maybe a year or two, but then I wouldn’t have anything to live on myself.  Where could I live?  How could I eat?”
                “The only alternative is to divest yourself of your assets so that you cannot be held legally responsible for paying for your wife’s care.  The you and she can both get assistance under the Medicaid program.”
                “Then I have to literally become a pauper before I can get any help?”

                “I’m sorry to say that’s true.”

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