On NPR this morning they had an interesting case:

A woman with {*filter*} cancer comes in with headaches.  Her doctor wants to
perform a CT scan to see if she has brain metastases.  The insurance company
says they will not pay for a CT scan unless she has brain metastases, not just
to see if she does (that's smart!).  Should the physician lie and say she does
so the insurance will pay for it, or just order it and let the woman fight it
out with the company if she doesn't have brain metastases?

Generalizing, should the physician ever lie to help the patient when the
--
------------------------------------------------------------------------------
Gordon Banks  N3JXP      |"I do not seek to follow in the footsteps of the men

------------------------------------------------------------------------------

Frankly, I wouldn't know what to suggest. I don't think the insurance company
should practice medicine without a license [which they are doing here]
nor do I think the physician should 'practice insurance' when making optimal
medical decisions. Perhaps the best solution for the patient/doctor vis a vis
the insurance company would be to take the approach that the insurance company
is acting in 'bad faith'....which they most certainly are. I don't know what
this would involve in practical terms.

JB

Interesting.  I just received the 2nd edition of CASES IN BIOETHICS:
Selections from the Hastings Center Report.  While there are 60 various
different cases and commentaries thereon, none of them include issues
where an insurance co would refuse to pay for a test that was needed in
the physician's judgement unless the physician lied.  But surely these
sorts of things happen all the time.  (I even recall my own dr asking me
at my last regular physical whether to put on the ins form that it was a
routine physical, or should it say that I had come in with a complaint so
that the ins would pay?) Hmmmm.

I hope that medical ethics texts and source books begin including such
cases as this in their research data soon, as it definitely seems like an
increasingly important issue in biomedical ethics.

BTW - the closest cast to this one in CASES IN BIOETHICS was one in which
a hospital administrator threatened to fire an ob/gyn who was performing
*too few* c-sections compared to his colleagues.  It turned out that this
doc believed in attempting VBAC with most patients, while his colleagues
did not.  But the hosp admin pointed out that the hosp *lost* money on
{*filter*}l births, but made money on c-sections.  Therefore, doctors who
didn't perform enough c-sections were losing the hospital money, and
might force it to close its emergency room facilities (which were
subsidized by the rest of the hospital's income).  Therefore, they WANTED
doctors to perform c-sections rather than {*filter*}l deliveries whenever a
plausible case could be made for doing so, because they hospital needed
the insurance payments for c-sections in order to stay afloat.

In this case, in general the commentators pretty much agreed that a
physician's responsibility is to individual patients, one at a time,
rather than to society-as-a-whole.  So even if society-as-a-whole would
lose from the closing of an ER, it was important not to perform
unnecessary surgeries on individuals just to make enough money from
insurance to prevent its closing.  However, when I teach this case, I
contrast it with physicians' decisions to give or withhold antibiotics,
for example.  

The contrast case is the child who shows up in the ER on Thursday night
before a 3-day holiday weekend, with symptoms that suggest strep (this,
before the QuickStrep test was available, tho).  If the overall social
good comes first, the doc should wait for the test result before deciding
whether to prescribe antibiotics, to ensure that they are not being
prescribed unnecessarily (social risk of superinfections,
antibiotic-resistant bacteria developing, etc.).  But if the individual
patient's well-being is paramount, then 4-5 additional days of high
fever, vomiting & sore throat can likely be avoided by giving the
antibiotic when the child presents, rather than waiting for the (very
likely positive) test result, even though BY THE BOOK the doc should
wait.

At least that's what every cost-benefit analysis I've seen on the
subject would suggest to do for {*filter*}s, and in children, with
a higher incidence of strep, this would make even more sense.

--
David Rind

Jackie

--
------------------------------------------------------------------------------
Gordon Banks  N3JXP      |"I do not seek to follow in the footsteps of the men

------------------------------------------------------------------------------