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Running head: Ethical Case Study

Ethical Case Study- Chronic Illnesses and the Uninsured

Elisha Sonson

Argosy University

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Ethical Case Study- Chronic Illnesses and the Uninsured

Abstract

Through the examination of a case study of an uninsured graduate student suffering from

chronic crohn’s disease, this paper discusses the ethical dilemmas that affect the uninsured. The

main purpose of this case study is to explore, from an ethical perspective the key ethical issues,

questions and choices the uninsured patients are forced to make. This paper also examines a case

study; respectively the case study of Madisyn Whitfield (2009) and the ethical decisions that

health care providers have to make are addressed.

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Ethical Case Study- Chronic Illnesses and the Uninsured

Madisyn should not have to choose between paying for her medication and hospital bills,

because it is unethical for healthcare professionals to provide unequal care to patients because

they are uninsured.

Ethical decision-making is required when healthcare professionals must balance the needs

and interest of the patients, the organization and society. Those involved in this decision making

process must consider ethical principles such as justice, fairness, as well as professional ethical

standards and codes. Today, many factors have contributed to the growing concerns in healthcare

organizations with ethical dilemmas including issues of access and affordability, pressure to

reduce cost, and the biggest issue among all, providing medical care for the uninsured.

By definition, an ethical dilemma involves the need to choose from two or more morally

acceptable course of action; when one choice presents selecting the other; or the need to choose

between equally unacceptable alternatives. These dilemmas for example, are when patients find

themselves having to choose between paying rent/mortgage and filling prescription, leaving them

to utilize the services at emergency room hospitals in hopes of getting treatment without the out-

of-pocket expense. The primary function of the emergency department is to stabilizing the

condition of critically ill and injured patients. In addition, the emergency department often serves

as the sole provider of primary care services for the uninsured in the United States. Reports have

shown that the emergency department in the United States has to contend with a substantial and

disproportionate increase in the number of patients seeking treatment without medical insurance.

Using data from an article, Krisha McCoy (2010) estimated 46 million people living

without health insurance in the United States. McCoy further states that working families make

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up 4 out of 5 people who have no medical insurance (2010). These families put their health needs

in jeopardy because they simply cannot afford to pay for medical care, which in the long term

causes their health to deteriorate. Another article from the National Conference of State

Legislature, explains that because family incomes fall behind the health care inflation, non-group

health coverage becomes unaffordable to most families NCSL (2010).

First, let me bring to your attention the case study of Madisyn Whitfield. Madisyn is a 25-

year-old graduate student from the West Coast who suffers from a chronic inflammatory disease

of the gastrointestinal tract called ‘crohn’s disease’. Although there is no cure for crohn’s

disease, with proper care and treatment, Madisyn could control the flare-ups that is associated

with the disease. When left untreated, Madisyn’s disease causes severe flare-ups and damage to

her intestinal tract causing her the possibility of requiring surgery. For Madisyn, time, financial

constraints, being uninsured and stress from her studies did not allow her to care for herself, as

she would, thus worsen her condition (Anna Kozas 2010).

Madisyn’s health was quickly declining, and she made the ultimate decision to take some

time away from school and continued to work to support herself. Soon after, Madisyn began

experiencing pain, which she knew was a periodic occurrence of her kidney stones. Madisyn

health had declined so badly, she had become malnourished and dehydrated. Thanks to her

friends who came to her aid, Madisyn was rushed to the emergency department for help. Her

condition required her to receive IV fluids, x-rays, and numerous blood test and surgery to

remove her kidney stones. To this young graduate, as well as the doctors, Madisyn knew she

needed to take better care of herself and continue her medication (Anna Kozas 2010).

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Madisyn also knew her surgery would require her to stay at the hospital and extra 2 or 3

days to recuperate. However, without health insurance, Madisyn knew it would be impossible for

her to keep up with her treatment, let alone covering the cost of her surgery. Madisyn made the

ultimate decision and she did what many uninsured patients do, she signed out AMA (against

medical advice). Madisyn knew she needed time that she barely had to figure out her options, if

any (Anna Kozas 2010).

Should the hospital give Madisyn free care?

Should the hospital provide care at a reduce cost?

Who decides when the uninsured receives care?

Should the cost of health care be equally affordable to all?

Is the uninsured deserving of free health care?

While it may seem that, the hospital has an ethical responsibility to offer Madisyn free

care; it is not always that easy. Like most patients, Madisyn’s case is unique. Her condition

became worst and she needed the necessary medical attention in order to regain her life back. In

Madisyn’s case, the hospital and its organizational body, needs to make the ethical decision to

provide free care for Madisyn. Providing free health care for one would eventually lead to

providing free health care for all. Considering the rest of the community, providing free hospital

care for the uninsured community means that the hospital will be financially burden and

eventually unable to provide care. The role of the hospital is to provide care without risking its

financial resources. Given those reasons, the hospital is not acting unethically to refuse care for

those who cannot afford it (Anna Kozas, 2010).

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Because of cases such as Madisyn’s, hospitals now have to make an analysis of each case

they are presented with, in order to continue serving its community (Anna Kozas, 2010). It is

very much unethical for hospitals to refuse patients the care that they need but some hospitals

would consider their financial loss to provide quality of care to patients. The better option in this

case for Madisyn and the hospital would be to provide preventative care at a reduce cost. This

would be a better alternative, as it would benefit both parties and subsequently the community.

The continued debate over the financial responsibility of uninsured patients like Madisyn

produces many questions on ethics, responsibility of health care professions and the role of the

community in general. This case raises key ethical questions on the issue of hospital versus

patient responsibility regarding health care. Referencing this case is it fair to say that Madisyn or

her peers have a responsibility to purchase health care insurance to ensure that they will not be a

financial burden to the medical system if they fall ill. In my opinion, I believe that the hospital

has a responsibility to provide unlimited care to uninsured patients. These patients should not be

denied access to health care services if they end up in an emergency room. Uninsured patients

rely on a safety net of hospitals, community clinics or physicians who will see them without

payments. Many of these uninsured patients find themselves having to cut back on filling

prescriptions or follow-up care until they really need to or until their condition becomes a

medical emergency. Like Madisyn, many of patients have to choose between paying for basic

needs versus health insurance.

It is the responsibility of the hospital and its emergency staff to provide ultimate care to

patients whether or not they are financially capably. Patients like Madisyn that require

hospitalization for further care should not be denied access because of financial consideration. It

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is also the ethical responsibility of the discharging medical facility to provide follow-up and

adequate medical resources for patients like Madisyn, to prevent the development of subsequent

foreseeable emergencies resulting from original medical problems. When follow-up care is

received, it becomes easier for medical professional and patients to manage and treat these

underlying conditions effectively. Emergency physicians and personnel should not allow cost

constraint to impede the quality and type of care rendered to uninsured patients.

Outlined in a recent article, Carol J states the U.S. Census Bureau reported the total number

of uninsured people in 2003 at 45 million (2005). This statistic is a percentage of the growing

number of working and non-working families who cannot afford to take on the responsibility of

health care cost. For the few families who have health care, their employers have no choice but

to raise their share of cost leaving these employees with the only option of paying or dropping

their coverage altogether (Carol J. 2005). Are these families having any other option when they

cannot afford the cost of their health care coverage anymore? What other option do these

families have when a medical emergency presents itself? The answer is simple; they have to rely

on the safety nets of hospitals, community clinics and other medical facilities that would address

their medical needs without up-front cost. The one disadvantage to the uninsured is that what it

might cost patient X who has health care insurance for an x-ray would be double or triple for

patients like Madisyn and other families alike who are uninsured.

The unethical practices of health care providers against the uninsured have become the

norm at many hospitals and medical facilities. Uninsured patients are forced to sign out AMA or

suffer the consequences in the hands of debt collectors due to part of the outrages charges that

they are being billed for routine care. Carol J. added in her article that many patients are angered

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by the outrageous charges that they are billed by these departments for the same routine services

that insured patients have to undergo (2005). These practices are disreputable and uninsured

patients should not be force to pay extra for routine exams that others are being charged less

simply because they have coverage. Are the principles of ethics being practiced by health care

providers? As revised and approved by the American College of Emergency Physician (ACEP)

in 2009, the code ethics for emergency physicians affirms that physicians should embrace patient

welfare as their primary professional responsibility. The code also establishes that physicians

should respond promptly and expertly, without prejudice or partiality, to the need of emergency

medical care (ACEP). For the uninsured person, the battle is a long lost because there are many

who are in support of these practices.

While the uninsured patient feels that, the hospital has an ethical obligation to provide

emergency care; those who oppose this contention feel differently. The opposition feels that is

not the responsibility of the hospital and its emergency professionals to provide free health care

for the uninsured. Some argue that hospital are faced with financial crisis due in part by

uninsured patients, while others see it as one of the most challenging dilemmas facing health care

institutions and its executives. Star-ledger, Martin Tsai, states in a 2010 article, that

reimbursement for medical procedures account for many of the financial issues hospital face due

to caring for the uninsured (2010). In the article, Martin gave an example of New Jersey and

Washington, who faces much of its financial problems due in part of providing care for the

uninsured. Martin stressed that out of the $7 million spent only a fraction, $ 1.8 million

respectively was reimbursed to offset the cost of the care provided (Martin Tsai, 2010). It is

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argued that with this growing number of hospitals facing financial problems, many will end up

shutting their doors indefinitely.

Many uninsured patients believe that they should not be blamed for the financial issues

these hospitals face because they are entitled to health care just as much as those with health care

insurance do. However, those who feel differently have no doubt that their community hospitals

are sinking because of the high amount of unpaid bill caused by the uninsured. Reed Abelson

(2010) argues that the nationwide cost of unpaid hospital care in 2008 was $36 billion. Reed also

stated that many hospitals across the nation would feel the crunch by 2014, when the unpaid debt

increases to an estimated $58 million. Many fear the problem will not be resolved because the

number of uninsured people would continue to rise (2010).

Medical practitioners have an ethical obligation to provide care for their patients. Ethical

principals provide guidance for practitioners about what their obligations entail. The American

Medical Association (AMA) has suggested a framework for ethical analysis that medical care

professionals can use to determine the ethical course of actions to follow in any given situation.

Some of these approaches involve having ethical principles and moral and legal principles. When

faced with situations involving ethical decision-making, medical practitioners should utilize

these approaches until decision is reached. Some dilemmas can be resolved without the

application of ethical principles; however, other such as violating patient confidentiality would

require the analysis of ethical principles.

As the number of medically uninsured patients like Madisyn increases, medical

practitioners have an ethical obligation to provide care for their patients. Ethical principals

provide guidance for practitioners about what their obligations entail. The American Medical

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Association (AMA) has suggested a framework for ethical analysis that medical care

professionals can use to determine the ethical course of actions to follow in any given situation.

Some of these approaches involve but not limited to having ethical, moral, and legal principles.

When faced with situations involving ethical analysis, medical practitioners should utilize these

approaches and guide themselves with the normative effort to identify standards that ought to

guide human behavior. While each school of ethical analysis has its own system of analysis,

three key issues must be included in the analyses of health care for the uninsured. They are social

justice, autonomy and beneficence.

Ethical Analysis I

First, because the policy of medical institution affects the way in which people receive

health care, it is essential in ethics to consider what these medical institutions and their policies

owe to patients like Madisyn. In addition, paying attention to social justice will ultimately mean

consideration of the distribution of health care. Michele Chandler, M.P.A.S, employs that

theories of justice in application to health care emphasizes principles for fair distribution of

benefits as the basis for defining the right to medical intervention (Chandler, 2006). This means

that the ‘common good’ should be consistent with social justice (2006). John Mills Utilitarianism

view on ethics supports this ethical analysis, which seeks to create the ultimate good. For

example, should Madisyn be closed off from accessing health care because of her inability to

pay? The ethical analysis of social justice does not require affirming that all people must have

the same scale of access to health care, but the analysis of social justice will require credible

validation for any differences in access that do occur. Although it may be difficult to carry out

broad social analysis when considering the needs of a patient, it will remain critical for providers

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to make ethical analysis not to lose sight of the circumstances in which patients like Madisyn are

ill and the forces that impede their treatment.

Ethical Analysis II

Next, the capacity at which patients choose or become free of control from another is

termed as autonomy (Meridian-Webster Thesaurus 2010). This capacity states that patients are

not biological robots and have the power and ability to make informed choices and decisions.

Ethical standards are emphasized in respect to this capacity and the uninsured like Madisyn

should not be used as if they had cognitive incapacity. According to Lesage & Portenoy, based

on human dignity, medical providers should allow competent patients to consent to medical

decisions without coercion (2001). Physicians should act with moral and ethical justifications

and not force a patient to make those choices based on the physicians own self-interest or as if

the patient was incapacitated (2001). Pauline Lesage Md. & Russell K. Portenoy MD (2001)

explains that informed consent implies that medical decisions must be a collaborative choice

between patient and physician (2001). In addition, in considering treatment for patients, ethical

analysis must be made of whether or not a particular treatment or policy respects the patient’s

independence. For example, medical professionals should not make medical decisions for

Madisyn because she does not have the financial means to contribute towards her health care.

Ethical analysis in medical treatment should concern itself with patient’s autonomy.

Ethical Analysis III

Last but most importantly, promoting the health of patients without doing harm. Medicine

has imposed upon itself and society has come to demand, a standard of beneficence, which

means the effective support for human welfare. For example, this beneficence is concern with

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medical professionals promoting patient health through educational programs and other medical

resources. Concurrently, beneficence in medicine also concerns itself with promoting the

medical welfare of individual patients. Roy Branson states in his article that health care should

be distributed according to utility (Branson 2004). This account simply means that resources and

obligations should be distributed in a way to maximize the overall benefits of all patients.

Beneficence in its most minimal form, calls for physicians to do no harm when they treat

patients. Ethics in this form requires that physicians actively promote the welfare of patients and

refrain from harmful behaviors. In addition, physicians should aim the ethical analysis of

medical care in terms of beneficence, namely, their consonance with promoting human welfare

for patients.

To conclude, as the number of medically uninsured patients increases, so too grows the

number of patients like Madisyn who rely on the safety nets such as emergency rooms and

community clinics for health care. As part of a medical network, emergency medical providers

will continue to grabble with the mounting challenges of caring for an increasingly ill

population. Collectively, clinical, practical and ethical analysis supports these medical providers

involvement in improving the quality of care available to the uninsured. Serving patients

effectively requires not only scientific and technical competence, rather the moral and ethical

competence of what should be done. As emergency physicians and emergency personnel,

continue to confront difficult emergency issues, ethics should remain central to the clinical

practice of quality health care. The uninsured should be given the same level of care, as the

insured and financial constraint should not impede the judgment of the responding professional.

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References

Abelson, R (2010), New York Times, Bills, stalled, hospitals fear rising unpaid care

http://www.nytimes.com/2010/02/09/health/policy/09hospital.html?pagewanted=1

American College of Emergency Physicians, Practice Resources; Codes of ethics for emergency

physicians Retrieved from the internet on June 4, 2010 at

http://www.acep.org/practres.aspx?id=29144

Branson, Roy. (2004). Ethical Issues in Health Care, Washington, District of Columbia, US: US

Department of Health and Human Services, PsycEXTRA, and EBSCOhost (accessed June

20, 2010

Carol, J. (2005) Health Financial Management, Policies and practices for uninsured patients’

practical strategies: the number of uninsured patients is growing. What can you do to

help your organization address this issue? http://www.allbusiness.com/health-care-

social-assistance/362462-1.html

Chandler, M. (2006), The rights of the medically uninsured: An analysis of social justice &

disparate outcomes, Journal of Health & Social Policy, Vol. 21 (8)

Kozas, A. (2009) Santa Clara University, Markkula Center for Applied Ethics, the Case of

Madisyn Whitfield: Chronic Illness and the Uninsured

http://www.scu.edu/ethics/dialogue/candc/cases/chronic.html

Lesage, P. MD. & Portenoy, K. R. MD, (2001). Ethical challenges in the care of patients with

serious illness: Department of pain, medicine & palliative care, Beth Israel Medical

Center New York, Journal of Medicine Vol.2 (2).

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McCoy, K. (2010) Navigating the System: When you’re Uninsured

http://bidmc.org/YourHealth/HolisticHealth/HealthcareCenter.aspx?ChunkID=134191

Merriam-Webster Dictionary, Thesaurus (2010), retrieved from the internet on June 19, 2010 at

http://www.merriam-webster.com/thesaurus/autonomy

National Conference of State Legislatures: Issues and Research on Access to Healthcare and the

Uninsured, Retrieved on the Internet on May 20, 2010 at

http://www.ncsl.org/IssuesResearch/Health/AccesstoHealthcareandTheUninusredOverview

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