Ethical Debate

Case Study 1
NURS362
By: Sean, Marie, Rose, & Hillary
Case Study 1
A 27 year old nursing student has just graduated and
developed a rare and life threatening illness, a progressive
muscular degenerative disorder which causes significant
pain. A new procedure or therapy has been found to improve
life expectancy. The physician feels this may be the best hope
for his patient and refers patient for treatment. The patient is
low income and has government assisted health
insurance. The medical insurance denies coverage for this
procedure as it is new, experimental, and not covered under
the stated policy. It is expensive and although the company
who has this "cure" has discounted the cost, it is still
unaffordable for this patient. The patient states, "I can't believe
I am going to die from this because I'm poor." The hospitalist
stabilizes his condition and writes for patient to be discharged.
The family is seeking legal advice to sue the medical
insurance, hospital, and physician.
This poses a couple questions
1. Did the doctor even consider the young patients
insurance policy? Or simply, did the doctor just think
of the procedure and whats best?
2.Is it ethical or morally right, for a hospital to
discharge a patient who is stable, yet dying?
3.What about hospice, or palliative care?
4.Can the patient appeal the insurance company,
and demand coverage?
Joke or Real life?

HMSA Coverage in Hawaii
All care you receive must meet all of the following Payment Determination
Criteria:
For the purpose of treating a medical condition.
The most appropriate delivery or level of service, considering potential
benefits and harms to the patient.
Known to be effective in improving health outcomes; provided that:
-Effectiveness is determined first by scientific evidence;
If no scientific evidence exists, then by professional standards of care;
And If no professional standards of care
exists or if they exist but are
outdated or contradictory, then by expert opinion; and
Cost-effective for the medical condition being treated compared to
alternative health interventions, including no intervention. For purposes of
this paragraph, cost-effective shall not necessarily mean the lowest price.
Services that are not known to be effective in improving health outcomes
include, but are not limited to, services that are experimental or investigational
HMSA continued
Experimental or Investigational Services
Under the HMSA Medical Plans: A medical treatment, procedure, drug, device, or care is experimental
or investigative if:
The drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug
Administration and approval for marketing has not been given at the time the drug or device is furnished.
The drug, device, medical treatment, or procedure, or the patient informed consent document utilized with
the drug, device, treatment, or procedure was reviewed and approved by the treating facility's Institutional
Review Board or other body serving a similar function, or if federal law requires such review and
approval.
Reliable evidence shows that the drug, device, medical treatment, or procedure is the subject of ongoing
Phase I or Phase II clinical trials; is for the research, experimental study, or investigational arm of ongoing
Phase III clinical trials; or is otherwise under study to determine its maximum tolerated dose, its toxicity,
its safety, its efficacy or its efficacy compared with a standard means of treatment or diagnosis.
Reliable evidence shows that the prevailing opinion among experts regarding the drug, device, medical
treatment, or procedure is that further studies or clinical trials are necessary to determine its maximum
tolerated dose, toxicity, safety, efficacy, or its efficacy compared with a standard means of treatment or
diagnosis.
For the purposes of this provision, "Reliable Evidence" shall mean only:
Published reports and articles in authoritative medical and scientific literature.
The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying
substantially the same drug, device, medical treatment or procedure.
The written informed consent used by the treating facility or by another facility studying substantially the
same drug, device, medical treatment, or procedure.
how research can be approved
The Nuremberg Code - Set of provisions for
research that must be followed for the federal
government to approve research.
http://www.hhs.gov/ohrp/archive/nurcode.html
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Who is covered?

Options for patient
Ask about alternatives - Covered by insurance, just as effective
Investigate clinical trials - If you're a candidate for a clinical
trial, its sponsors probably will cover the cost of many tests,
procedures, prescriptions and doctor visits.
Get a second opinion - Another physician may suggest
alternate treatments, or he or she may confirm the advice of
your primary doctor.
Suggest a payment plan - If the treatment is essential and not
covered by insurance, ask your doctor's office to work with you
to pay the bill over a period of time.
Appeal to insurance coverage
http://www.hhs.gov/healthcare/rights/appeal/appealing-
health-plan-decisions.html
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