Metropolis Hospital is facing mounting deficits due to reduced medicare reimbursements, new guidelines and parameters from HMOs, and increased costs associated with the latest medical technology. The deficits put the entire hospital at risk of closing.
Through city and state contracts, a metropolis gets reimbursed for a certain number of indigent patients (those without health insurance and the means to pay for treatment) it treats. Some laws require the hospital to accept patients who present themselves with a genuine medical emergency.
Madge, an African-American, arrives at the emergency room of Metropolis. She is 78 and complains of chest pains. After an extensive examination, she is diagnosed with a cancerous tumor in her lung. Madge also appears to have emphysema – probably caused by her smoking.
Recommended treatment includes:
Removal of the tumor – with follow-up chemotherapy
Chemotherapy alone
The prognosis for someone of her age, condition, and history of smoking is only a 10-20% chance of surviving five years. The difference in removing the tumor through surgery with follow-up chemotherapy only increases the five-year survival rate by 5% (15-20%).
Chemotherapy alone is much less expensive. Dr. Ken argues that Madge only has Medicare – and that Medicare will not adequately compensate the hospital. The state and city indigent care amounts have already been exhausted. He believes that since her prognosis is terrible either way – scarce hospital resources should be diverted to those with a better chance of recovery and long-term life. He recommends chemo alone.
Dr. Karen argues that Madge is already socioeconomically disadvantaged. She is black and has suffered discrimination and less-than-equal earning opportunities. Why should she continue to get less-than-optimal care? She recommends surgical removal of the tumor and chemo.
Nurse Juan argues that it is her decision. She is a human being with the right to make health care decisions. We must honor her choices.
Nurse Martha argues that Madge may have a right to make a decision – but she has no right to waste scarce medical resources. She argues against surgical removal and proposes chemo alone.
Lee, a nurse practitioner, argues that the decision is not a matter of using/not using limited resources – but asking what is in the best advantage of Madge. Will the surgical removal of the tumor cause her more harm and risk with a tiny hoped-for advantage?
The risk-management team raises issues of a potential lawsuit if she is not treated and an advocate or lawyer files suit that she was discriminated against. The risk management team argues that surgery is more expensive than chemotherapy alone but cheaper than a protracted lawsuit. They say that even if surgery and chemo are more harmful and produce no extra benefits – it is better to err on the side of over-treatment than risk a lawsuit for under treatment.
Identify types of justice/ethical arguments laid out by the various members of the team.
Which do you think has the most merit and why?
In healthcare situations – is there a preferred justice approach? Why?
What are the competing obligations/values/interests in this case?
