Health insurance ethical dilemma

[takashi]

Lets assume one of your patients works for a company and receives health insurance that covers a variety of health expenses such as prescription drugs. Now lets assume that this patient has a family member who needs an expensive drug but cant afford it. This family member is also one of your patients. The patient then asks you to write her a prescription for the drug so she can claim it under her company insurance and thereby obtain the drug for free. This patient would then give it to her family member. Would you write the prescription for her?

[future_doc]

Absolutely not! Doing so constitutes fraud, a breach of ethics, can lead to sanctions by the medical association including possible suspension and you can be blackmailed to do it again or perform other illegalities under threat of revealing your secret. Notwithstanding empathy for the family, it is a no-no. You can always make a financial contribution for the drug to be obtained legally by the family member, thereby not acting fraudulently and exposing yourself to criminal and professional sanctions.

 

Michael Jackson's doctor crossed the line and he is now charged with manslaughter. He didn't have a clue as to the potential consequences of his inappropriate actions.

[rmorelan]

Absolutely not! Doing so constitutes fraud, a breach of ethics, can lead to sanctions by the medical association including possible suspension and you can be blackmailed to do it again or perform other illegalities under threat of revealing your secret. Notwithstanding empathy for the family, it is a no-no. You can always make a financial contribution for the drug to be obtained legally by the family member, thereby not acting fraudulently and exposing yourself to criminal and professional sanctions.

 

Michael Jackson's doctor crossed the line and he is now charged with manslaughter. He didn't have a clue as to the potential consequences of his inappropriate actions.

 

I love ethical problems, they are a lot of fun to work out- future doc is right of course on the primarily legal grounds presented but let's assume it is an interview question. How exactly would you respond? What are the ethical considerations?

 

Maybe I just miss being a TA

[Starling]

1) giving that drug to someone who doesn't need it means that it goes on their medical record. If that person has to go in to another doctor for whatever problem it will come up and prompt an investigation from the doctor. It can also mess up their patient history

 

And conversely, there would be no record that the patient actually taking the drugs is taking them, so if they go to another doctor they could be given something that would interact with said drug, but the doctor/pharmacist wouldn't know. Or, the patient could mention to another doctor that he's taking this drug, which could result in someone trying to figure out how he got them.

[future_doc]

a slippery slope begins with what one believes is a relatively simple action (aka 'infraction') that has ethical and legal implications.

 

Once we let other issues preoccupy/cloud our judgment, we are beginning to jeopardize our own professional interests/standing as well as the patient. Dr. Conrad Murry is an extreme example where it appears that he allowed greed to cloud his judgment (due to the financial mess in which he was embroiled personally) and he madde a decision presumably under the belief if not him, than it wouold just be another doctor. Not only did he not receive a penny in fees from his patient who death it would appear he caused, but he will likely loose his licence to practice and may end up doing jail time. It is far simpler to maintain the highest of ethical standards - thereby protecting the patient asnd yourself. "Do no harm".

[future_doc]

I love ethical problems, they are a lot of fun to work out

 

Interestingly, when abortions were illegal, doctors had the etihcal problem of breaking the law for giving an abortion to a patient versus refusing in the knowledge that she would go to a back alley butcher, unqualified, no sterile instruments or location, where the lielihood of her death was great. Whatever payment they may have received was not worth the risk they took personally and professionally, yet many did for the protection of their patients.

 

And some of those who did not perform abortions and convinced the woman to have the child helped informally in arranging an 'adoption' which was not quite legal to a good home for the child of an unwed mother incapable of providing for the child herself.

 

Indeed, there were ethical considerations and legal considerations - and sometimes, what was the right thing to do e thically was not legal. Today, I think things are more black and white with less grey.

[scrub]

Also determine if the drug is a necessary treatment for the patient's condition. If it is then it should be covered by their plan. If it isn't covered, for whatever reason, there's likely a reasonable alternative that is. Talk to the patient about alternatives, concerns, etc.

[rmorelan]

Indeed, there were ethical considerations and legal considerations - and sometimes, what was the right thing to do e thically was not legal. Today, I think things are more black and white with less grey.

 

I am not so sure it is any less grey now that it ever was. We are still arguing about abortion (or at least the access to it), health care resource allocation, patient rights both in terms of the young and old, euthanasia, and the looming genetic manipulation debates are are going to have soon enough.

 

Can't really think that we have actually resolved anything particularly well in the last 30 years of so. Makes it pretty interesting!

 

On the purely practical side, they are still using ethical questions galore on interviews. Must be some reason for it

[future_doc]

Very interesting indeed - lots to grapple with! And, of course, there have been recent advances on the so-called vegetative state as new means of communicating with patients are being found after years of treating thek as being in a vegetative state.

[oldnewbie]

I have a much more grey scenario where the health of 2 patients are on the line. Let's say you have a couple as patients for over 20 years. You know they are poor and have to prioritize their expenditures.

They both need a number of medications, but the one they need the same is blood pressure medication. They both need the same dose and brand. One spouse qualifies for the govt prescription drug plan because of age, one does not.

You as the doctor discover that they have been purchasing only one prescription (that's on the govt plan) and not the other. They then split the medication thinking some medication will do better than no medication. You know they cannot purchase the 2nd prescription, and despite your best efforts they will continue to split the one prescription.

Do you continue to allow both of them to be harmed by insufficient doses, or do you double the one prescription (on the govt plan) so that they will both be protected? Is helping the patient paramount or not?

[aKGDH]

I'm quite sure you cannot double the dosage and still write that prescription only for one person. What is required is that you sit both of them down and discuss their situation. You need to make it clear that the prescription given to one of them is for only that one person and that any modifications made to the original prescription is not only less effective (if even effective at all) for that one person, but dangerous for the other person. You must try your best to convince the patients not to continue with their course of action.

 

Also, why is there no drug treatment for the other person? It's hard for me to imagine that the government drug plan is the only available one for that person. I suppose the situation may be sticky if we are in the States, with privatization of health care, but don't the very poor and elderly have separate medical plans? And if we are in Canada, why is this an issue? I'm not an expert on the Canadian health care system (yet ), but I thought the elderly were covered by the government.

"Pharmaceutical medications are covered by public funds for the elderly or indigent..." (it's from wiki, but wiki used a credible source).

 

Ultimately, as the doctor you cannot 'fake' your way around things, even to help patients. You must be entirely upfront about what you do and maintain your integrity and values, including attempting to convince the patient of the right thing to do (and the stronger your relationship with your patients, the easier it will be to convince them), as well as help explore other options for the 2nd person.

[pharmed]

If there's a generic version of or something similar to the antihyptertensive meds, switch the patient over to that one. Also, are there any services in Ontario for people on welfare or living below the poverty line to have access to coverage on Rx meds?

[aKGDH]

"The Trillium Drug Program (TDP) is intended for Ontario residents who have high prescription drug costs in relation to their net household income."

 

Would this patient not qualify for this Ontario drug plan?

[Jochi1543]

Also determine if the drug is a necessary treatment for the patient's condition. If it is then it should be covered by their plan.

 

Not always the case. Sometimes the best treatments are not covered, and the pt has to suffer from extensive side effects and low effectiveness of the alternatives.