Dilemma 8Terea McCarthy

Hannah is 87 years old and lives in a nursing facility. She is mentally lucid but semi mobile. She has suffered a debilitating stroke. She also has arteriosclerotic heart disease and diabetes. Currently she is experiencing chest pain. At one point she describes it as intermittent and another time as continual. She is now a medicare patient but once was a member of a HMO.

Dr. Nicely is Hannah’s physician. She informs him of the chest pain and that she has heard that bypass surgery might could help her get rid of the pain.

Dr. Nicely is not supportive of the idea, but explains the risks involved. He makes sure she knows that she might not survive the procedure. Maybe even emphasizing that risk. (Is he trying to sway her decision ?)

Hannah listens carefully and with some hesitation decides she wants to have the procedure.

In her mind she is living with constant chest pain and it is limiting her in every aspect of her life. She really does not feel she can go on living this way.

Hannah even tells Dr. Nicely “If I don’t survive the surgery it would not be the worst possible outcome.”

Autonomy is the principle in consideration.

The patient has decided what she wants to do. Made an informed decision. Her mental status is not in question, she is capable of making the decision. In fact, she has made the decision even after the information was presented in a jaded manner.

The physician and the patient are at odds.

Whose decision is it really?

Now that Hannah has made her decision and Dr. Nicely does not agree, he goes in search of back up for his position.

He contacts the HMO director to see if the procedure will be approved. If it is not then he can go back to Hannah and tell her “Well I would do it but they won’t pay for it.”

What a non-professional way out!

This brings the principle of veracity to the table.

If this is the situation then did Dr. Nicely practice veracity?

Did he ever tell Hannah he was not supportive of the bypass and the reasons why? It appears that he may not have actually informed her of those things. But led her to believe that bypass was a distinct possibility by discussing the risks and allowing her to make a decision concerning it.

Misleading someone is not practicing veracity.

The decision now is at the HMO director’s level.

What things does he have to consider?

Hannah’s age

current state of health

wishes/decision

how would the procedure be paid for

Hannah is covered by medicare and was previously a HMO member. Could it be that she paid premiums for years and years before using any services. Has she really paid her dues already to the point that all services she would ever need would have been paid by those unused years? The HMO received premium monies from her for years and she received no benefit or reimbursement for services unused. They had her money and she had what?

This is the point where not only justice but also distributive justice raise their heads.

Justice: the concept of moral rightness based on ethics, rationality, law, natural law, religion, fairness or equity along with the breach of said ethics.

en.wikipedi.org/wiki/Justice

(Treating people fairly)

Distributive justice: Concerns what some consider to be socially just with respect to the allocation of goods in a society.

En.wikipedi.org/wiki/Distributive_justice

(Allocation of limited resources)

The HMO director has many issues to wrestle with when making his decision.

Known

Hannah is in pain.

Hannah’s decision is to have the surgery.

She has underlying disease processes.

She is 87 years old.

Hannah is already in a debilitated state.

Unknown

Will she survive the surgery?

Will it alleviate her chest pain?

How much longer will Hannah live?

Will there be other complications in relation to the surgery?

Will the surgery be paid for?

Does the HMO director decide that Hannah is too old and not a quality candidate for the surgery, thus denying coverage. He would be participating in distributive justice at this juncture. What makes the director the one to decide the “Quality” of life Hannah should have to settle for? She would have to live with the pain from now on? She has already said that death would not be the worst thing, indicating that living with this type of constant pain is worse.

Does the director decide to cover the surgery and practice justice and support Hannah’s autonomy? It is her decision and even if things do not go well, it was still her choice. If she dies then the HMO will never be out anymore money on her. If she lives then maybe she will live long enough to make the decision beneficial financially.

What is your decision?

Was there ever any other treatments offered to Hannah?

Surgery is not the first line of treatment in many cases.

Where the alternatives for surgery really investigated with Hannah in a manner that made any of them plausible?

Who/What is influencing Dr. Nicely the most? Patients or financials.

Who/What will influence the HMO director the most?