Welcome to Ethics Consult — an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case, and then we provide an expert’s commentary.
Last week, you voted on whether it’s wrong for a doctor to allow two look-alike sisters to commit well-intentioned insurance fraud.
Is it ethical for Dr. Bock to pretend he has not discovered the sisters’ deceit and to provide “Vivien” with lifesaving care?
Yes: 20%
No: 80%
And now, bioethicist Jacob M. Appel, MD, JD, weighs in:
Healthcare fraud is a serious problem in the U.S. The Wall Street Journal estimated that fraud accounted for 10% of all Medicare spending in 2013, or $58 billion. The Department of Health and Human Services warned in 2016 that 12% of Medicaid expenditures (more than $139 billion) reflected “improper payments.” The phenomenon is also rampant among the privately insured.
This fraud is not a victimless crime. These costs are either passed along to the general public through increased insurance rates, decreased services, or, in the case of government programs, tax hikes. In Jeanne’s case, the sisters are in essence stealing $150,000 from the taxpayers.
Yet ethical assessment often requires an understanding of context. One must ask: Why is Jeanne stealing this expensive treatment from her fellow human beings? Critics of the existing healthcare structure might well argue that she is doing so because society has created a system that is inherently unjust. A wealthy nation ought to be able to provide lifesaving chemotherapy at an affordable cost to a law-abiding middle-age woman in desperate need. While some believe that spending almost 18% of our gross domestic product on healthcare may be too much, there is also a compelling argument that 18% is too little, if women like Jeanne must otherwise go without care.
That additional expenditure would have to come from somewhere — whether military hardware or education or consumer goods — but most of us, a priori, would gladly trade a few consumer goods for affordable chemotherapy if we were to develop cancer. So a case can be made that Vivien and Jeanne are acting dishonestly in the context of an unjust system.
One of the most difficult decisions physicians confront regularly is to what degree to look the other way when patients engage in activities that are illegal but may enhance their health or improve their welfare. These situations might include patients who split their pills with relatives or those who import cheaper medications illegally from abroad for their personal use. Such cases might also include homeless people who feign illness to gain admission to the hospital, seeking clean beds and warm meals that they have been unable to obtain elsewhere.
Dr. Bock ought to encourage “Vivien” to investigate any honest means for obtaining her treatment affordably. He might also mention to the sisters that they are likely to get caught: if he could see through their deception so easily, other providers are likely to do the same — and many will have a zero-tolerance policy.
If Dr. Bock does look the other way, at no profit to himself, he might argue that he is doing on a larger scale what many other providers do every day with far smaller deceptions — aiding individual patients at the expense of healthcare insurers in the context of an often-Kafkaesque medical system. Whether he should do so is a different matter entirely.
Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.
Check out some of our past Ethics Consult cases:
Wrong to Offer Cheap, Pirated Version of Drug?
Cut Health Insurance for Risky Activities?
Stop Life Support for a Tax Break?
Source: MedicalNewsToday.com
