Chapter 3: The Moral Climate of Health Care

Section 7. Decision Scenarios

How do principle of ethics apply to cases?

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

According to HCFA, the Federal Health Care Financing Administration (www.hcfa.gov/medlearn/faqphys.htm)    it is illegal for a physician to refer his patients to a diagnostic health service with which the physician has a financial relationship. This is considered a conflict of interest. Such facilities include things like medical labs, radiology services, physical therapy facilities, and so on. The rationale behind the HCFA ruling is that a physician would refer a patient excessively to a facility he owned, and the cost for the care would be passed on to the government. HCFA further reasons that there are so many non-doctor owned facilities out there that no one will be hurt by the regulation.

Consider a hypothetical case that may have led to this sort of regulation. Let's say Dr. Smith is a family doctor. As part of his practice, he orders blood tests on his patients, referring these patient to a hospital or local lab. These tests are paid for by either the patient, insurance company, or the government. One day, it occurs to the shrewd Dr. Smith that if he built his own outside lab and ran it cost effectively, he could refer all of his own patients for testing and reap the profit. What's more, since he thinks that annual blood tests are part of good medical care, he'll refer every one of his patients to his own lab for a whole battery of tests, whether they're necessary or not. In so doing, he'll make a ton of money. In this case, what has begun as an acceptable venture -- providing efficient laboratory care -- has turned into an abuse because of Dr. Smith's greed. The conflict here is the clash of values between profit, economy, and efficiency (which serve the doctor,) and the patient's right to freedom and autonomy (to choose his own lab) and dignity and comfort (not to be subjected to unnecessary testing.) The government has tried to address this conflict through regulation.

Now for a different case. Here, a hypothetical Dr. Jones, a radiologist, did pioneering work with a revolutionary new body scanner. The prototype, the only one in the country, is up and running near Dr. Jones' practice. Furthermore, Dr. Jones has a financial arrangement with the R&D types who paid for and built the scanner. Jones wants to refer some of his own patients for the sort of lifesaving information only the scanner can provide. But HCFA says absolutely not. Jones will have to refer such patients to another doctor, who in turn can send them to the new scanner. Here, there are several levels of conflict. Jones loses his autonomy to provide the most timely care he can. By having to run around with paperwork and jump through hoops, not to mention unnecessary delays, the patient is treated with less than dignity and respect. The government, which set up this situation in the first case, catches deserved heat from all sides. Thus, in certain circumstances, in attempting to regulate abuses, the regulation can actually make the situation worse. --Jon Shobin(2002)

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Article from The Batavia Daily News, Thursday, February 14, 2001.

STUDY FINDS MANY DOCTORS DON'T FOLLOW URINARY INFECTION GUIDELINES

As stated, doctors may be inflating the costs of treating urinary infections and possibly promoting resistance to antibiotics by ignoring treatment guidelines? according to a new study. The study was published in the Archives of Internal Medicine. The study suggests that doctors are driven by drug company promotions to use newer, more expensive drugs. Researchers from the University of Chicago and Standard University studied 1,478 cases with urinary tract infections between 1989 and 1998. They found that only 24% of individuals were prescribed antibiotics recommended by the Infectious Disease Society. This percentage was down from 48% from the previous decade.

Dr. Elbert Huang, of the University of Chicago said, "Some of the drugs being prescribed are many times more expensive than what is recommended." The guidelines of the Infectious Disease Society recommends prescribing trimethoprim-sulphamethoxazole costing only $1.79 for a 10 days. 30% were prescribed nitrofurantoins such as Macrodantin costing $20.34 for 10 days, and 29% prescribed fluoroquinolones such as Cipro costing $70.98 for 10 days. These percentages were part of the study of the 1,478 participants.

Huang, is stated saying, "there is also a concern that having several classes of antibiotics in use at the same time might cause infections to become resistant to all those classes at once." Guidelines are established to prevent resistance. Dr. Thomas Hooton, an infectious disease specialist at the University of Washington in Seattle said he doesn't fault doctors for using alternatives. He said,? Some say resistance to trimethoprim-sulphamethoxazole is increasing, and want to use the antibiotics that is most likely to succeed.?

It is stated in article that on the West coast there is a one -third resistance, East Coast a 7% resistance, and in the Mid West a 14% resistance.

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In health care, medicine, and medical research there often occurs a clash in values. These conflicts exist amongst the providers and between the providers and the recipients of care. Recently a physical therapist was involved in a situation where there was a clash of values between two providers.

Mr. C was admitted to the hospital with a diagnosis of a fractured right hip. Mr. C is an eighty six year old male with a fairly significant medical history, including the early stages of dementia. Mr. C was operated on by the orthopedic surgeons, and ended up needing a total hip replacement because the fracture was so extensive. During surgery Mr. C experienced some minor cardiac complications and was sent to the ICU post-operatively. The next day the physical therapist was sent in to evaluate Mr. C. The therapist found Mr. C to be quite confused, to the point where he could not follow simple one step commands. It is quite common for someone of Mr. C's age to become confused after surgery from the anesthesia and the pain medicines that are given to comfort the person. The first day Mr. C required maximal assistance to get in and out of bed, perform sit to stand transfers, and was not able to take a step, even with maximal assistance of two people. Over the next few days Mr. C became less confused and began to slowly progress with physical therapy. By his sixth post-operative day Mr. C was able to get in and out of bed with minimal assistance, go from sitting to standing with minimal assistance, and was walking about 30 feet while using a rolling walker. Also by the sixth day, Mr. C had reached his baseline mental status; which was alert and orientated times three, but somewhat disinhibited. Mr. C had the tendency to say exactly what was on his mind at any particular point in time. Now the surgeon asked the physiatrist, Dr. H, to come and evaluate Mr. C for the in-patient rehab program at the hospital. This is where the clash in values started.

In the hospital it is the physiatrist's decision as to who gets accepted to and rejected from the rehab program. The decision is supposed to be based on the person's medical status, whether or not they could tolerate three hours of therapy a day, and if they would benefit from continued in-patient rehabilitation. Dr. H has the tendency not to accept people to rehab who are confused or that may be a discharge problem, even if they meet all of the criteria. Dr. H performed his consultation and denied Mr. C for the rehabilitation program. In Mr. C's chart Dr. H stated that he was denied further rehabilitation in the hospital because Mr. C had plateaued with therapy and recommended that Mr. C be sent to a nursing home to continue his therapy. But later that day, the therapist overheard Dr. H talking to one of the resident physicians and he said that Mr. C was not accepted to rehab because he is confused and "will require a lot of work."

A clash of values was now evident between the therapist and Dr. H. The therapist was appalled when he heard this reasoning behind the decision. The therapist thought that Mr. C was an excellent rehab candidate. Mr. C was still progressing with therapy and his mental status was not an issue in his ability to participate in therapy. Dr. H was placing his value of having an easy discharge of the person above the health and welfare of the person. Dr. H was using the principles of egoism in his decision. It was in the best interests of Dr. H to deny rehab to Mr. C so that Dr. H would not have to deal with problems that may arise while Mr. C was on rehab. The therapist questioned Dr. H as to why Mr. C could not stay for rehab. Dr. H offered a few reasons; one being that Mr. C would be here a long time. And since the hospital receives a flat rate for the rehab stay, if Mr. C is here for a long time it would not be profitable for the hospital. Now Dr. H was now placing the value of profit before the welfare of the patient.

A few days passed and Mr. C continued to progress. The therapist went to Mr. C's medical doctor, who also is the medical director of the hospital, and explained that Mr. C had been denied rehab but has been doing much better, and now would be a good rehab candidate. The medical doctor went to Dr. H and requested a re-evaluation. Now Mr. C was at a supervision level with his bed mobility, transfers, and walking. Dr. H now accepted Mr. C to rehab, because he was doing better, no longer posed to be a discharge problem and would not need to be in the hospital much longer. Dr. H was still placing profit over the welfare of Mr. C, but at least Mr. C was going to get the rehabilitation that he needed. The therapist was happy that he had advocated for Mr. C and had stuck to his values, to do the best thing for the person. As it turned out Mr. C was on the rehabilitation unit for only six days and was discharged without any problem. --Douglas Graudon (2002)

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Here is a case that happens all too often, and that is insurance fraud. It is a big deal to the people that pay for insurance. This is personal case that continues to occur. Every year Joseph would go to his family eye doctor to get his eyes examined. This seems like a normal situation that people do. There is certainly no harm in getting your yearly eye exam, which insurance covers, but that is not the case when Joseph walks into Corrections Eye Center. Joseph understands and knows what is going on with this company, but has yet to inform anyone. Upon receiving an eye exam, Joseph then has to sit with his optometrist, Dr. Sebastian, in order to order a new pair of glasses, which the insurance covers a free pair of glasses or contacts every other year. This seems like another harmless visit to Corrections Eye Center, until the day Joseph receives a letter in the mail from his insurance company stating that he will have to pay $200, because the company would not cover that part of the bill. This seems reasonable to Joseph until he looks at his bill, and finds that there are a bunch of added treatments, tests, and a bunch of other stuff that Joseph never received. This frustrates Joseph so much that he refuses to send in the $200 to Corrections Eye Center, because 75% of the listed tests and treatments were never done on him. Months go by and Corrections Eye Center continues to bill him, and he still refuses to pay his portion of the bill. Unfortunately insurance fraud happens a lot more than we are aware of, and if we can al get together then we can stop this.

The conflict in this real life situation is the fact that Corrections Eye Center is billing Joseph's insurance company for tests that Joseph never had done. Even though the charges that were being billed to the insurance company are reasonable, but it is just the fact of the matter. There also is a conflict between the individual, because he refuses to pay for something that he is almost positive was not done to him. However, there is that little bit of doubt in his mind that maybe these tests could have been done, but he cannot quit recall 100%. He is not positive enough to say something, so basically Joseph is breaching a contract with Corrections Eye Center for not paying his portion of the bill. There is no reason Corrections Eye Center is ripping off the insurance company, but the company continues to do so because nothing is said and the insurance still pays for most of it. ==Kevin Masick(2002)

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A 37 year old woman came into our family practice for the fourth week in a row complaining of a severe headache, this time coupled with blurred vision. This woman had seen the same doctor on each visit. This doctor attributed her symptoms with high blood pressure and proceeded to change her medication yet one more time. As a precaution, he ordered a CT scan. He tells the patient this test should be done at her leisure; he doesn't think it would show anything. The patient leaves our office and goes to work. The doctor gets a call an hour later that this patient has collapsed at work and was rushed to the hospital. A few hours later the patient was diagnosed with an aneurysm and was brain dead. This patient has a husband and two children under the age of 5. The surgeon tells the husband that his wife has no chance of recovery. The surgeon wants the husband to agree to have his wife's organs harvested. This procedure would insure the death of his wife almost immediately. The surgeon pleads with the husband that there are patients who can survive a long healthy life with the use of his wife's organs. The husband refuses. The wife lasts for a few months. She is off the life assisting machines but still brain dead. The only portion working is her brain stem, which keeps her breathing on her own. To the amazement of everyone, this patient opens her eyes and can now respond to pain by moaning. She cannot move. She is literally trapped with herself. She cannot speak. She can follow you around the room with her eyes only. She is kept on high doses of pain meds. The husband decides to terminate her life by pulling the feeding tube and starving his wife to death, which is very painful. The doctors won't write the order. The family goes to court and eventually wins. The woman dies weeks later from starvation.

In this case the values of each individual were in conflict. The husband was grief stricken and didn't want to loose his young wife. He had hoped that she would recover. He didn't want to have his wife's organs harvested ? he was against it all along. The surgeon was acting in the interest of not only the patient, but of other patients as well. The surgeon knew that there would be no chance of recovery to a full or even partially dignified life for this patient. The surgeon also knew all of this patient organs could have been harvested to give to other patients who needed the parts to survive. This was a very tough case for everyone. The grief stricken husband left with two children to care for versus the doctors who could save the quality of lives of others. The doctor and the husband were both trying to act on the best interest of the patient. I believe that the doctors? actions were based on the need to benefit everyone, while the husband was trying to help himself. I do not know if the husband ever produced the drivers license of his wife, as asked.

The doctor who saw this patient in the office had consulted with a malpractice attorney almost immediately. He questioned whether he could have done something sooner to prevent this. After some research, the attorney tells him that the treatment he rendered was within the scope of proper care for this patient based on her symptoms. The attorney suggests that any doctor would have made the same decisions. The family did not sue the practitioner. Had they even seen the chart, they would have seen the note documented by the nurse who called the patient and recommended she go for the CT scan immediately.- - Andrea Santora(2002)

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In health care, there often occurs a clash in values. These conflicts exist between providers and recipients of care. One example of this would be a case involving Mr. Smith and his surgeon Dr. A.

Mr. Smith chose to have an elective surgical procedure performed by his doctor. He chose to have a vasectomy performed. Prior to his surgery, he is asked to sign a surgical consent form. The form describes the surgical procedure, how the procedure is performed, and the possible complications of the surgery itself. Listed in the release, are the possibilities of death from anesthetic reaction, the possibility that in future the surgery may reverse itself, and finally the possibility of generalized unexplained pain for years to come. Understandably, Mr. Smith is hesitant to sign the form, and voices his concerns to the Doctor. He is assured that this is a formality. That while there is a possibility of complications, that they are rare. He is told that this doctor has performed thousands of this type of procedure, and that he rarely hears of any post op complications. Mr. Smith feels reassured, and agrees to sign the release.

The surgery is performed, and Mr. Smith is discharged. He is given post op instructions that he follows, but two days later calls his doctor due to a persistent fever and pain in his lower abdomen. The doctor prescribes antibiotics, and has Mr. Smith follow up in a week. A week later the fever has abated, but the abdominal pain has not. The doctor assures him that this is normal and that with time this pain should abate.

Six months later Mr. Smith is still complaining of persistent abdominal pain that is actually extensive enough to hinder his everyday lifestyle. Over the next six months, Mr. Smith has consulted his physicians numerous times. Numerous antibiotics and other medications later, he confronts his doctor with his concerns that this pain may be a permanent complication of the surgery. The doctor agrees that this is likely, and reminds Mr. Smith that this was always a possibility. Dr. A. reminds him that he signed a surgical release form for the surgery, and that this form made him aware of the possible complications of the surgery.

Mr. Smith feels somewhat betrayed and with a loss of trust in his doctor, requests a second opinion. An associate of Dr. A. is consulted and agrees that Mr. Smith has a post op complication. When asked if this is a possible complication due to some mistake performed by Dr. A, the colleague skirts the issue. Mr. Smith feels that he can no longer trust his doctor, and seeks an opinion outside of this practice. When he consults Dr. D, he is told that he is suffering a complication of the surgery itself. That while not a common occurrence that it can happen if the surgeon makes a miscalculated incision. He tells Mr. Smith that this condition is permanent, that medication can with time relieve most of his pain, but that this is no cure.

Mr. Smith is grateful to finally have a diagnosis, but is distraught that this condition will be a chronic problem. He feels that he was misled when he questioned the surgeon on the surgical consent form. He felt that he was not properly prepared for the possibility of complications. He believes that important information may have been withheld or downplayed in fear that he would choose not to have the surgery. As a result of this he was misled into prematurely signing the surgical release form, and in effect enabled them to put him at risk of being harmed. - - -Sandra Dowd(2002)

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One situation that has increasingly become a threat in modern medicine is antibiotic resistance of many strands of bacteria that were once treatable, but are now incurable and even deadly. Antibiotic resistance is caused by, prescribing an antibiotic for a viral infection, not finishing a prescription, and unsanitary conditions in a hospital. The conflict in antibiotic resistance occurs between the recipients of cares lack of knowledge of bacteria infections, and the doctor's ability to write an antibiotic prescription to satisfy a personís needs.

An example of this would be two parents bringing a child to the doctor complaining that the childís ear is hurting and the child is up all night screaming, which it turn keeps the parents awake at the same time. After a thorough examination the doctor concludes that itís not a bacterial infection, and that the best thing to do is allow the childís immune system to correct the problem. The doctor explains this to the parents and the possible effects of prescribing an antibiotic that will not help the child in this situation. Two very exhausted and concerned parents plead with the doctor for some type of prescription. So the doctor writes a prescription for an antibiotic knowing that in the long run it may cause harm to the child and others.

It is clear that there is a breakdown of communication between the health care provider and its recipient, which results in a class of values. The parents are concerned with the individual; in this case itís their child. Where the doctor is concerned about the possibility of contributing to bacterial resistance to antibiotics of the general public or social institution. These humanitarian and economic values respectively are always clashing. In the case of antibiotic resistance clashing values leads to many untreatable bacterial diseases that were once manageable. An example would be the increase of deaths due to drug resistant forms of tuberculosis (TB) in industrial nations.- - - James Dargan(2002)

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In a prominent hospital in NYC, Mr. A has been admitted on two previous occasions related to his chronic vascular disorder. After the first treatment he partially lost use of his right arm. The second stroke led to paralysis of the right side of his body.

Mr. A informed the physician that he did not want to be treated or saved the next time he has a stroke, in order to avoid being totally paralyzed and remain alive. Mr. A was a reputable stock broker and had an image that he did not want to be tainted. He could not bear his colleagues envisioning him as a disabled individual.

The conflict is that the physician believes that he can prevent Mr. A from being paralyzed and he has good hope that with rehabilitation, Mr. A may be able to regain partial use of his right side. The HC institution does not want another patient that can be saved to die, because it will be reflected in their annual documentations. This will jeopardize the standing of that institution.

The main values in conflict are the Economical values (Institution and HCP) vs. Humanitarian values (patient). The patient is concerned about his dignity, freedom and his individuality. However, the physician and the institution are more concerned with advancing technology, efficiency, profit and the good health of Mr. A. What the HCP seem to omit is their concern for his welfare. Welfare is defined as being: 'the state of doing well especially in respect to good fortune, happiness, or prosperity'. Happiness being the keyword, the operation does not satisfy Mr. A's need for happiness. - -  -Ben Echeazu(2002)

 

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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