Welcome to Ethics Consult — an opportunity to discuss, debate (respectfully) and learn together. We select ethical dilemmas from anonymized real patient care cases and provide expert commentary.
Last week you voted on whether it’s wrong for a doctor to allow two sisters who look alike to commit insurance fraud with good intentions.
Is it ethical for Dr. Bock to pretend not to have discovered the sister’s deception and offer life-saving treatment to “Vivian”?
yes: 20%
No: 80%
And now bioethicist Jacob M. Appel, M.D., J.D. says:
Healthcare fraud is a serious problem in the US wall street journal estimates 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 spending (more than $139 billion) reflected “improper payments.” This phenomenon is also prevalent among private insurance subscribers.
This scam is not a victimless crime. These costs are passed on to the general public through higher insurance rates, lower services or, in the case of government programs, higher taxes. In Jeanne’s case, the sisters are essentially stealing her $150,000 from taxpayers.
However, ethical evaluation often requires an understanding of the context. We have to ask: Why is Jeanne stealing this expensive remedy from her fellow humans? Wealthy countries should be able to provide life-saving chemotherapy at affordable prices to law-abiding middle-aged women in desperate need. Some believe that spending nearly 18% of the gross domestic product on health care is too much, but there are also compelling arguments that 18% is too little.
That extra spending has to come from somewhere – military equipment, education, consumer goods, etc. – but most of us, a priori, will make some consumer goods affordable if we get cancer. I would gladly exchange it for chemotherapy at a reasonable price. It can therefore be argued that Vivian and Jeanne are acting dishonestly within an unfair system.
One of the most difficult decisions physicians face on a regular basis is to what extent a patient should be separated from others if they are engaged in activities that are illegal but may promote their health or improve their well-being. It means whether you take the view of These situations may include patients sharing drugs with relatives or illegally importing cheap drugs from foreign countries for personal use. Such cases may also include homeless people who feign illness in order to be admitted to hospitals, seeking clean beds and hot meals that were not available elsewhere.
Dr. Bock should encourage “Vivian” to investigate honest means of getting treatment at an affordable price. He may also mention to the sisters that they are likely to be caught: if he can see through their deception, other providers are likely to do the same, many with zero We will have a tolerance policy.
If Dr. Bock takes the opposite view and doesn’t do himself any good, he’s doing what many other health care providers do every day, on a much smaller scale, with much less deception. you might argue. The context of the often Kafkaish medical system. Whether he should or not is another matter altogether.
Jacob M. Appel, MD, JD, is Director of Psychiatric Ethics Education and a member of the Institutional Review Board at Icahn School of Medicine, Mount Sinai, New York City. He holds a M.D. from Columbia University, a LL.B. from Harvard Law School, and an M.B. in Bioethics from Albany School of Medicine.
See examples of past ethics consultations.
Is it wrong to offer cheap pirated drugs?
Cut health insurance for risky activities?
Stop-life support for tax relief?
.
