Case Scenario

As I was writing out a prescription for albuterol and steroid inhalers for a patient with asthma, she stopped me. “Could you please put my mother's name on that prescription? She has insurance.” I suspected she wouldn't buy the medication if she had to pay for it because she lives on a tight budget. She had been to the emergency department many times before, so I knew her asthma would worsen without treatment. We had no samples in the drug closet because they get used quickly for our many needy patients. I must have appeared uncomfortable, because my patient continued, “My usual doctor has done it before. My insurance from my new job should come through next month. Those medicines are so expensive.” I felt torn. Which is worse: cheating her mother's insurance company, or letting my patient go without needed medication? Her insurance company made a nice profit but withheld my group's bonus last year. I ended up not putting her mother's name on the prescription, but it didn't help me sleep well that night; I got a call from the emergency department saying that she was there.

Commentary

The scenario described above will become increasingly familiar to most practicing physicians over the next few years. Currently, we are witness to at least 40 million “medically indigent” patients without insurance and the number continues to increase.¹

Many other patients have insurance benefits that do not include prescription drugs. Even health care plans that include a prescription benefit are charging ever-increasing copayments—as much as $30 per prescription—necessitating painful choices for many.

Given the present state of health care in the United States, all of us who see patients will have to somehow resolve the dilemma apparent from this case. We must carefully examine the alternative choices and ultimately make a personal decision regarding the “better,” not the “best,” action. As I read this case (with an all too familiar nod), the tension I feel can only be relieved if I attempt to clarify my position about two competing ethical issues as well as my understanding of the nature of the doctor-patient relationship. Ultimately, as is the case in almost all ethical dilemmas in medicine, a series of practical considerations will move me further in one direction than another.

At its roots, the dilemma we see here requires us to choose between truth-telling (i.e., an ethical principle that has merit on its own without reference to whether it leads to good things), and utility (i.e., the greatest good for the greatest number). I doubt if any of us can claim exclusive adherence to either principle; lying to the Nazis to save hidden Jews would not insult our moral intuitions, but eliminating those who are “drains” on the societal purse for the good of the majority would. Is lying to the insurance company to protect a sick patient close enough to the Nazi example to permit it? Or does truth-telling win the day? Does a lesser lie make a difference in how we think about this case (such as writing “rectal bleeding” as the diagnosis for a routine screening colonoscopy)?

Alternatively, from the perspective of utility, does taking from the rich (the insurance company) to benefit the needy (the patient) promote the greatest good and therefore justify a decision to cheat? Or, does such an action raise everyone's insurance premium and detract from the overall utility?

To further clarify my own position, I must consider an additional idea: namely, the moral foundation of our obligation to patients. In a seminal essay on this topic published in 1979,² Pellegrino argues that the “ontological assault” imposed by illness on the patient, coupled with the “act of profession” by the physician, require a competency and an advocacy categorically different from all other fiduciary relationships. The nature of the “engagement with a patient” enjoins us to do everything we can to preserve or restore his or her health. The doctor-patient relationship for Pellegrino is a much different one than, say, that of a car salesman who is asked to fudge a loan application for a potential customer. Despite the “provider-customer” language that has characterized this relationship, I agree with Pellegrino and hold that we do have “moral” obligations to those we profess to heal.

When I acknowledge the special relationship I have with my patient, my openness to bending the truth in order to serve her direct interest is enhanced, particularly in the case of serious illness such as asthma. Now that I am leaning toward bending the truth to serve my patient's best interests, a number of practical considerations will lead me in one direction or the other. How well do I know this patient? Is her mother my patient also? Is this a one-time arrangement? Will I be able to follow up? What would happen to me if the insurance company did an audit?

Because these questions are not clearly answered from the case presented to us, I will make some assumptions. Assume that I know the patient and her mother (even though she has been to another doctor), and that this was a one-time situation. (If it were a chronic situation I would work to secure medicine through other means such as public assistance, detail people, etc.) My sense of patient advocacy and my consideration for the greatest overall utility would win the day over truth-telling. I would write the prescription in her mother's name and request brief follow-up with my patient in three days at no charge, at which time I would ask to see the medications. I would take my chances that this would not even be a blip on the insurance company's radar screen. Whether my group's bonus was withheld would not be a consideration. My decision in this case after all, was not made to get back at the insurance company; it was made to restore my patient's health.

Finally, unless we as physicians take the lead in advocating for available health care for every American, painful decisions such as these will need to be made on an almost daily basis. As family physicians, we especially need to be outraged that we practice our profession in a country where patients must sometimes choose between food and medicine, and doctors need to game the insurance companies to help alleviate patients' painful choices.