Thursday, June 28, 2007

Hospital Ethics

I'm presently doing Clinical Pastoral Education (translation: ministry interning as a hospital chaplain) and my group heard a presentation by the hospital's resident medical ethicist. She posed a dilemma for us: a child is strongly suspected of having meningitis and the doctors urge a lumbar puncture procedure. The parents refuse, insisting that they have heard too many bad things about this procedure. Should the doctors proceed with it anyway against the will of the parents?

The group came to a consensus that the hospital should proceed with the lumbar puncture, and the ethicist agreed. Now here's the question that I then posed to the group, and I'd like to know what you think.

Would it be ethical for the hospital to bill the parents for the cost of this procedure even though they did not consent to it?

25 comments:

the reverend mommy said...

Ten to one, the parents would never know and insurance will pay for it. Ethical? probably not. But some one will have to pay.

DannyG said...

Ideally, the hospital would get an emergency injunction to make it legal.

John said...

Ah, but this is a question of ethics, not legality.

DannyG said...

But making the procedure legal would make the billing there of legal. (and give it some moral authority as well, as some judge, somewhere would have ruled in the child's best interest).

Lorna said...

unethical to do it, unethical to bill it (even to an insurance company) ... unless in the best interests of the child which is always hard to determine.

with suspected meningitis - another procedure might work equally well.

Along the Narrow Path said...

Ethically, I don't think the hospital should bill for it because the hospital decided to do the procedure for the life of the child against the parents wishes. It is a hospital's mission to save lives, but that doesn't mean that they are bound to bill someone if the parents didn't sign off on it. Eat the cost.

John said...

But making the procedure legal would make the billing there of legal. (and give it some moral authority as well, as some judge, somewhere would have ruled in the child's best interest).

So if something is legal, it is therefore ethical?

Methodist Geek said...

It's right to do the procedure... parents rights stop when they stop acting in the best interests of their children. It's not right for the hospital to bill them for a procedure they didn't ask for. This is why health care ought to be free to patients.

I'd say it would be ok to bill their insurance company for it.

DannyG said...

Legality vs morality is a big question, especially with the history of the last century in mind. However, if one assumes a legal system which is, at it's core, at least an attempt to square morality and legality, then it can act as an authorative neutral third party to assess the best interests of the child away from the emotion and conflict

John said...

Methodist Geek:

This is why health care ought to be free to patients.

As long as we're repealing the Law of Scarcity, can we distribute free Lambroghinis, too?

John said...

Legality vs morality is a big question, especially with the history of the last century in mind. However, if one assumes a legal system which is, at it's core, at least an attempt to square morality and legality, then it can act as an authorative neutral third party to assess the best interests of the child away from the emotion and conflict

It is lawful for me to cheat on my wife. Does that make it ethical?

It is lawful for me to hate my neighbor. Does that make it ethical?

It is lawful for me to forsake the poor. Does that make it ethical?

The Holocaust, by the way, was completely legal under German law. Was it ethical?

Sanctimonious Hypocrite said...

"Ten to one, the parents would never know and insurance will pay for it." Well, except for the $2000 deductible and co-payment, and the $750 bill for unspecified "professional services" that will arrive eight months later. But no, it is not ethical to do it or bill for it. And the fact that 'ethicist' is a job creeps me out.

Andy B. said...

The decision to do the procedure was based on what would be best for the child, not on the cost. The hospital must be willing to cover the cost in this case, kind of a "money where their mouth is" situation.

Anonymous said...

John:

Great topic and some truly scary answers presented thus far. My favorite "gem" is:

"It's not right for the hospital to bill them for a procedure they didn't ask for. This is why health care ought to be free to patients.

I'd say it would be ok to bill their insurance company for it."


In the intereset of full disclosure, I am a physician. However, this topic - at least to me - seems more economic in nature than an ethical dilemma.

I would argue that it is ethical to bill for the procedure. The procedure was deemed to be necessary and in the best interest of the patient. There are plenty of procedures performed in hospitals and medical centers in the best interests of patients without consent. Feel free to spend some time at any Level One trauma center.
Those who advocate that hospitals should eat the costs, or bill the insurance companies fail to appreciate that you are just shifting the costs from one party to the next. No matter how much the costs are shifted around in clever shell games, those costs do not go away. Left unpaid or not billed, as others here have advocated, only increases the cost of healthcare.

FWIW with respect to "ethicist" and healthcare; every academic medical institution that I have been affiliated with, has had an ethics committee. In my experience, such committees are of great service to patients and the healthcare team. The committee is comprised of individuals from different disciplines (i.e.nursing, social work, pastoral care, medical, etc.)

Respectfully,
Joseph

truevyne said...

The question strikes a nerve for me. When my son was a newborn, the hospital asked to perform a lumbar puncture because he had a fever. This procedure is so common and so intrusive. I begged to accompany my son to comfort him, and the hospital outright refused as I would not be "sterile". Somehow, hospital staff could magically all become sterile, but I could not. Anyhow, the question is probably very common, but I still say it's up to the parents.

The hospital ethicist I know is a follower of Nietzsche, and I frankly don't find Nietzsche or this ethicist to be particularly ethical.

bob said...

John, Not only is it unethical it is money grubbing,bleed them til their dry mind set that hospitals tend to operate under. My wife had her second knee replaced last summer. While there her potassium level fell below normal. What does the hospital do ,they call in a dietician. Who immediately perscribes potassium pills. Now these pills are big enough to choke a horse and my wife has a hard time swallowing small pills. That evening while I was there the dietician came in and I asked about the pottasium level, just what is normal. Her level was 3.3 normal is 4.5 to 6.5, my question was couldn't she just eat extra bananas. You see we found out they do this frequently as a good way to bring somebody into the billing.

Which is why free medical (Non patient paid for) care would not work. The corruption and greed that would go into that sort of payment method would be astronomical

DannyG said...

John, that's why I said that it depends on the legal system. If you start with one which is grounded in a moral ethical system then the result(s), on average and over the long haul, should be ethical. Obviously, if you have a system which is not so grounded, results will not be so favourable.

Anonymous said...

John:

I'm astonished as more members from mensa chime in. On my score sheet, Bob moves to the head of the class with: "John, Not only is it unethical it is money grubbing,bleed them til their dry mind set that hospitals tend to operate under."

Let's quickly review:
A child is strongly suspected of having meningitis and the doctors urge a lumbar puncture procedure.

The parents refuse, insisting that they have heard too many bad things about this procedure.

The group came to a consensus that the hospital should proceed with the lumbar puncture, and the ethicist agreed.

Would it be ethical for the hospital to bill the parents for the cost of this procedure even though they did not consent to it?

Therefore we have a medically indicated procedure that is in the best interest of the patient being performed. The parents object not due to a second opinion or based on the best care for their child, but from hearing too many bad things about the procedure. Billing the patient is not unethical, nor money grubbing, nor a "bleed them til theirsic dry mind set".
Two aphorisms come to mind to those who oppose billing the patient:
1. You get what you pay for.
2. There is no such thing as a free lunch.

I'll close with a quote from a recent Walter Williams column: "if we wish to be compassionate with our fellow man, we must learn to engage in dispassionate analysis. In other words, thinking with our hearts, rather than our brains, is a surefire method to hurt those whom we wish to help."

Respectfully,
Joseph

Anonymous said...

what the hell is a lumbar puncture?

and don't we all know parent's who have refused "advised treatment" with the kids turning out just fine?

hurt murmurs at young ages, magically disappear by adulthood. expensive braces, ye the kid still has perfectly usable teeth.
and what of the medicines that create so many negative side affects, yet are so often prescribed for our young children.

Anonymous said...

A lumbar puncture is a diagnostic procedure performed to confirm or rule out meningitis. A needle is inserted into the lower back (lumbar area of the spine) to collect cerebral spinal fluid for culture. Cerebral spinal fluid bathes the meninges of the brain and spinal cord. Meningitis left undiagnosed and/or untreated is certain death, sooner than later.
I hope this helps.

Respectfully,
Joseph

the reverend mommy said...

I'll chime in again (my inner cynic spoke first):

in the hospital setting that I was associated with (at a Children's Hospital) it was first a given that, irregardless of any other factors that the child receive the best treatment possible for his or her condition. Case in point: giving blood products to JWs, even though it is anathema to them.

Secondly, they would have billed the large discretionary fund set up for the hospital for that purpose if need be (the huge fund that we do lots and lots of fund raising for)

The treatment of the child is paramount, not the payment for that treatment nor (particularly) the parent's wishes, if it is demonstrated to the medical team that the parent's wishes would be deleterious to the health of the child.

I was not fond of the second policy, but I never ever saw it used. Most parents agree with treatment protocols and are grateful for the health care.

Thirdly, I don't think there would be a leg for the parents to stand on in this case as meningitis is a public health threat and there are set protocols for suspected cases.

John said...

Joseph brings up that there is no free lunch. I am often amazed at those who advocate a free universal health care. By all means insist that each and every person acquire the best possible health care regardless of ability to pay, but money will not appear out of thin air to make this fantasy a reality. If we can't put every person in the world in a luxurious mansion, what makes anyone think that we can perform the same economic miracle in the field of health care?

Sanctimonious Hypocrite said...

You need a wand of deeming, like someone used above to deem the treatment appropriate. Just deem the bill payed. Or get a judge to expunge the bill; that would probably work too.

Seriously though, the reverend mommy's point about public health is valid, and not something I had thought about.

John Meunier said...

I'm not sure billing someone for a proceedure is ever a question of morality. The question is whether the parents are morally obligated to pay?

I'm curious how the group came to concensus that the procedure should be done over the objection of the parents.

Would it have been done over the objections of an adult patient?

John said...

Well, the group consensus was reached well before I was really onboard with the idea. But the consensus that formed resulted largely from being informed by doctors that this test was a prerequisite to the life-saving procedure which would follow if the test revealed that the toddler had meningitis.

I don't think that the group would have reached the same conclusion about an adult patient.