ETHICS

Philippe Martin
Ray Velasco
Riki Sakihara
Sayuri Yoshimura
Supattra Allen

SYNOPSIS

30 year old male patient

Patient has a rare life-threatening illness (a progressive muscular disorder that causes
him excruciating pain)
Patient has low income with government assisted health insurance.
Physician finds and refers patient to a new procedure found to improve life expectancy.
The procedure is very expensive.
Patients medical insurance denies procedure because it is:
o Experimental/New
o Not covered under stated policy
Company who found the cure offered it at a discount, but is still too expensive for the
patient
Hospital stabilizes and discharges the patient
Patient states I cant believe Im going to die from this because Im poor.
Patient and family are seeking legal advice to sue medical insurance, hospital, and
physician.

EVIDENCE
Ethical Analysis
Viewpoint

Patient:
Autonomy: Personal freedom
and right to make choices (in
this case, his autonomy is
affected by his low income and
restrictions from health
insurance.)
Patient is frustrated stating I cant
believe Im going to die
because Im poor.

Physician:
Veracity: An ethical duty to tell
the truth (about new treatment
option).
Nonmaleficence- ethical principle
stating the duty not to inflict
harm

Viewpoints
Insurance Company:
Hawaii Medicaid does not cover:
Services, procedures, drugs,
devices, equipment and
treatment that are
experimental, investigational, or
of generally unproven benefit...

Hospital:
Medical facilities are required by
law to treat patients, regardless
of their ability to pay under the
federal emergency medical
treatment and active labor act
EMTALA). However, once the
patient is stabilized, the
patient can be discharged.
Facilities have a general right to
refuse treatment if they have
no insurance or any other
means of paying for the
provided care.

Ethical Decision-making process

1. Gather the facts
2. Define the ethical issues
3. Identify affected parties (stakeholders)
4. Identify the consequences
5. Identify the obligations (principles, rights, justice)
6. Decide on proper ethical action and be prepared to

deal with opposing arguments

Gather the Facts

30 year old patient

rare life-threatening illness
Insurance wont cover experimental treatment referred by physician

Ethical issues
Physician found and referred patient to new treatment thinking it is
the best option for the patient.

Treatment will improve patients life expectancy.

Patient wants new treatment but cannot afford it and health
insurance will not cover it.
Company provided a discount to the treatment.
Patient and family threaten to sue medical insurance, hospital, and
physician.

Stakeholders
Every ethical dilemma involves more than one person. In ethical decision making, all parties
affected by the decision are called STAKEHOLDERS.
Primary stakeholders are:
directly involved in this situation, are directly affected by the decision, or have interests that should
be protected
Secondary stakeholders are:
so far removed from the situation that you dont have to worry about them, have delegated
responsibility to others, or interested observers but dont have any real involvement in the
situation.
Primary stakeholders
Patient
Family
Hospital

Secondary stakeholders
Insurance company
Company who found the cure

Consequences
Patient: Pain, suffering, death, hopeless/helpless, Money
Physician: Guilt, Bad reputation,
Hospital: Bad reputation, Lawsuit,
Insurance company: Bad reputation, Lawsuit

Principles, Rights, Justice

Patient
Autonomy: Personal freedom and right to make choices
Right to treatment
Deontology: approach that is rooted in the assumption that humans are rational
and act out of principles that compel them to do what is right.

Physician
Beneficence- ethical principle that one should do good and prevent or avoid
doing harm
Accountability- one should be responsible legally, morally, ethically, and socially
for ones actions
Nonmaleficence- ethical principle stating the duty not to inflict harm
Veracity- ethical duty to tell the truth

Principles, Rights, Justice

Hospital/Insurance company/Company who found the tx
Utilitarianism- ethical theory stating that the best decision is one that brings about
the greatest good for most people
Beneficence- ethical principle that one should do good and prevent or avoid
doing harm
Accountability- one should be responsible legally, morally, ethically, and socially
for ones actions
Nonmaleficence- ethical principle stating the duty not to inflict harm
Veracity- ethical duty to tell the truth

Ethical Action
ALTERNATIVE #1 Hospital provides treatment

Most hospitals have charity care programs to help cover medical bills for some families

Eligibility is usually based on income and savings

For example

Hospitals of all types have provided more than $326 billion in uncompensated care
to their patients since 2000 (AHA, 2012)

Hawaii Pacific Health provided $10 million in charity and uncompensated care in
2009 (Hawaii Pacific Health, n.d.)

Ethical Action
ALTERNATIVE #1 Hospital Provides treatment
Pros:

Support ethical principle of beneficence

Patient may receive free treatment that may improve his life expectancy

Promote good relationships between patient and health care team

Hospital will be responsible for the cost of treatment

Patient may receive lower standard of care due to reduced expense by the provider

Cons:

Ethical Action
ALTERNATIVE #2 Refer patient to Assistance Programs
There are a number of resources available to individuals who need help paying for medical
care and prescription drugs

Financial aid from hospital

Government assistance programs

Department of Health and Human Services (DHHS)

Government Benefit

Non-Profit Assistance Programs

Patient Advocate Foundation

The National Organization for Rare Disorders (NORD)

Co-Pay Relief Program

Ethical Action
ALTERNATIVE #2 Refer patient to Assistance Programs
Patient Assistance Programs (PAP)
Phamaceutical companies provide medications at little to no cost
www.pparx.org
Patient Assistance Program Resource Center
www.ashp.org/PAP/
Provides information about how to help patients obtain assistance
Pharmaceutical Reimbursement Resource Center
www.ashp.org/reimburse/
Provides information about how to help pharmacists and others
obtain proper
reimbursement under new federal rules
Association of Community Cancer Centers
www.accc-cancer.org/
Lists pharmaceutical manufacturer drug reimbursement hotlines
and patient
advocacy groups

HealthWell Foundation
www.healthwellfoundation.org/hw/index.aspx
Provides financial assistance to eligible patients for certain out-ofpocket
healthcare costs, including prescription drug coinsurance,
copayments, and
deductibles; health insurance premiums; and other selected out-ofpocket
healthcare costs
National Network for Health
www.nnh.org/
Includes an alphabetical list of foundations (available by clicking
on "Health
Foundations" or going directly to
www.nnh.org/NewNNH/foundations.htm)

Ethical Action
ALTERNATIVE #2 Refer patient to Assistance Programs
Pros:

Support ethical principles of beneficence, veracity

Patient may be able to afford the treatment if he receive financial assistance

Patient may improve life expectancy if he receives treatment

Hospital may avoid uncompensated treatment

Cons:

Patient may not qualify for any assistance programs

May delay the treatment

Patient still needs to pay if he is unable to receive full financial assistant

Ethical Action
ALTERNATIVE #3 Appeal the decision and have it reviewed by a third party
if your health insurer refuses to pay a claim The patient has the right to appeal the decision and have it reviewed by a third party.
You can ask that your insurance company reconsider its decision. Insurers have to tell you why theyve denied your claim or ended your
coverage. And they have to let you know how you can dispute their decisions.
Under the Affordable Care Act, you can submit an appeal of a denial when your insurance company decides:

that you are not eligible to enroll in the health plan

to not pay for a service that is a benefit under your plan

to reduce or terminate a covered service that you have been receiving under your health insurance

that care is not medically necessary

that you are not eligible for a particular benefit

that the treatment is experimental or investigational to deny/cancel your coverage

Your appeal should identify the insurance company's decision you are appealing and clearly explain the reasons why it should be reversed (
If the decision involves medical necessity, you should obtain a letter from your doctor stating why the requested service or treatment
meets the health plan's definition of "medically necessary" and any other criteria.

http://www.healthlawadvocates.org/tools/publications/files/0017.htm

Ethical Action
ALTERNATIVE #3 Appeal the decision and have it reviewed by a
third party
Pros :
-

Support ethical principles of autonomy and beneficence

Might overturn the insurance decision.
When your life or health is in jeopardy, insurers are required to offer an expedited appeal procedure.
The health plan must issue its decision within 72 hours.
Collaboration between patient and provider

cons :
-

Appeal may be denied

May delay the treatment. Decision can take up to 30 days
Patient may need assistance through the appealing process
Patient needs to do research
It will likely be an overwhelming process
May have to appeal more than once

Alternative #3
According to the article, Dale (2010), a patient with multiple sclerosis was denied insurance
coverage of $5,000 for functional electrical stimulation therapy suggested by his
neurologist.
the insurance company initially denied coverage stating that the therapy is not a benefit
covered under the insurance plan, the device was experimental, and there was a lack
of medical and scientific data to support the efficacy of the device.
He was able to overturn the his insures decision by double checking his insurance policy;
appealing with materials on the device from respected sources and with letters from his
health-care team, he was able to get the coverage he needed.

Ethical Action
ALTERNATIVE #4 Lawsuit
Human Right to Health

Every person has basic human rights that are common to all human beings
regardless of income, sex, race, ethnicity, national origin, language, religion,
sexuality, age, or disability. These rights are the same for everyone, and they exist
independent of government recognition.

Guarantees a system of health protection for all

Everyone has right to health care they need

The human right to health care means that hospitals, clinics, medicines and doctors
services must be accessible, available, acceptable, and of good quality for everyone
where and when needed.

Ethical Action
Alternative #4 Lawsuit
Human Right to Health is Recognized in:

Universal Declaration of Human Rights (Article 25)

American Declaration on the Rights and Duties of Man (Article 11)

International Covenant on Economic, Social and Cultural Rights (Article 12)

Relevance in the United States

According to Yamin (2005) the United States has been uniquely averse to accepting
international human rights standards and conforming national laws to meet them.

The United States is also the only industrialized country in the world that does not provide

a plan for universal health care coverage and legal recognition of a right to care,
(Yamin, 2005).
In 2011, Vermont became 1st state in country to pass a law for universal, publicly financed
health care system based on human rights principles (NESRI, 2014).

Alternative #4 Lawsuit- cont.

Emergency Medical Treatment and Active Labor Act (EMTALA)
EMTALA requires hospitals with a capable emergency room that accepts Medicare or
Medicaid provide emergency health care treatment to anyone needing it regardless of
citizenship, legal status, or ability to pay.
Hospitals cannot discharge or transfer a patient requiring emergency treatment except with
informed consent or stabilization of the patient.

The patient must be able to perform all self care with or without medical equipment. These
include breathing, feeding, mobility, dressing, personal hygiene, toileting, medicating, and
communicating.

Recommended Ethical Action

We would recommend referring the patient to an assistance
program (#2). Patient is more likely to receive treatment by getting

help from financial assistive programs because the hospital has

denied treatment. Getting an appeal for the decision may be time
consuming and potentially denied. Furthermore, the patient may
potentiially not win the lawsuit since the patient was stabilized before
discharged.

References:
American Hospital Association. (2012). American Hospital Association Uncompensated Hospital Care Cost Fact Sheet. Retireved from
http://www.aha.org/content/12/11-uncompensated-care-fact-sheet.pdf
Cherry B. & Jacobs S., (2011). Contemporary nursing: issues, trends, & management. St. Louis, Elsevier Mosby.
Dale, A. (2010). Money matters: Winning an Insurance Appeal. Retrieved from
http://web.a.ebscohost.com.ezproxy.library.kapiolani.hawaii.edu:8080/ehost/pdfviewer/pdfviewer?vid=86&sid=a144e4d3-871a-460c-8dd00107942ff3c5%40sessionmgr4002&hid=4107
Hawaii Health Systems Corporation. (n.d.). Retrived from http://hawaii.gov/hhsc/policies-andprocedures/Finance/FIN%200520(060104)_w%20attch.pdf
Health Law Advocates (2010). Retrieved from http://www.healthlawadvocates.org/tools/publications/files/0017.htm
National Economic & Social Rights Initiative (2014). Retrieved from http://www.nesri.org/programs/what-is-the-human-right-to-health-and-healthcare
Yamin A. E., (2005). The right to health under international law and its relevance to the united states. Am J Public Health. July, 95(7): 1156-1161.