Eyeworld

JUN 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/78708

Contents of this Issue

Navigation

Page 55 of 79

56 EWOphthalmology Business June 2012 Ethical issues in everyday ophthalmologic practice The ophthalmologist's obligation to treat by John Banja, Ph.D. John D. Banja, Ph.D., ethical issues editor F or this ethics column, I thought I'd discuss a query to the ASCRS listserv that poses an interesting and important ethical dilemma. Here it is: A relatively poor, immigrant popu- lation lives near one of our offices. Although one of our physicians speaks their language, we have resisted market- ing our services to them because of con- cerns that they are uninsured. Our fear is that a patient might come for a first exam and pay cash. At that exam the patient is diagnosed with something that requires continuing care such as glaucoma. But suppose the patient doesn't have the money for regular follow-up exams and treatment? Are we required to continue to see this patient for free because we made the initial diagnosis of glaucoma? You should know, by the way, that our office sees plenty of patients pro bono, but we are concerned about an obligation of con- tinued, free treatment. This dilemma calls up a number of ethical and legal questions. For example, does the standard of care obligate the ophthalmologist to treat? Would the ophthalmologist commit negligence in failing to con- tinue treatment? Would he or she be abandoning a patient who is diagnosed with glaucoma but not subsequently treated? Is the oph- thalmologist bound by a "rule of res- cue," such that allowing the patient to leave is ethically (and possibly legally) impermissible? I was interested in finding out what the American Medical Associa- tion's 2010-2011 Code of Medical Ethics said about a problem like this, but I found various passages either vague or contradictory. For instance, section 2.03 of the Current Opinions says, "A physician has a duty to do all that he or she can for the benefit of the individual patient" and that "non-medical criteria, such as ability to pay … should not be considered." On the other hand, section 2.095 states, "In determining whether particular procedures or treatment should be included in the adequate level of health care," cost is a legiti- Source: Thomas Northcut/Lifesize/Getty Images mate criterion to consider in with- holding care. Still further, section 8.021 says, "Placing the interests of patients above other considerations, such as personal interests" is re- quired of doctors, but section 8.11 says, "Physicians are free to choose whom they will serve." And then there is section 8.115, which says, "Physicians have an obligation to support continuity of care for their patients." So how does this all bear on the question of an obligation to provide continued, free treatment? I would suggest that in this glaucoma case, there is no such binding obligation. The primary reason is that these pa- tients are presumably not in an emergent situation such that upon leaving the physician's office, they would lose their vision completely within hours. On the other hand, if an emergency intervention was re- quired to prevent the patient from becoming blind or seriously im- paired, the ophthalmologist would be very foolish to be primarily thinking about his or her reimburse- ment because refusing to treat in such instances can indeed amount to "abandonment." In a true emer- gency wherein the patient's condi- tion is utterly precarious, the ophthalmologist would either have to do the (life- or function-saving) procedure or find a peer who would. Emergency situations call up what has been termed the "rule of rescue," which is an idea popular- ized by the ethicist Albert Jonsen back in the 1980s. But invoking the rule of rescue in our present case seems too much of a stretch, as it is usually reserved for life or death situations. Of course, there's absolutely nothing stopping an ophthalmolo- gist from doing such cases pro bono, but the obvious ethical problem— and it is a real ethical problem—is the extent to which pro bono work might compromise the solvency of a physician's practice. This can trans- late into ethical patient care issues as the clinic might not be able to afford needed equipment or person- nel because too many patients are being treated for free. But what about charging paying patients more for their procedures in order to make up for the lost revenue from free care, which is the way we used to do it in the pre-managed care era? Today, such a practice wouldn't seem fair as paying patients would have no say in the matter but are simply being used, possibly against their will if they knew, to offset fi- nancial losses incurred by free care to the uninsured. So what should our ophthalmol- ogist be advised in the above sce- nario? First of all, does he or she really know that the patient cannot pay? I don't think there would be anything wrong with the ophthal- mologist or, more likely, an office administrator developing and ex- plaining a payment plan to unin- sured patients and making it clear that payment is due on each subse- quent visit. Or the ophthalmologist might do the case pro bono, but then will be faced with figuring out how large an income loss the prac- tice can sustain once the word gets around and then figuring out which cases are most deserving. I suspect some ophthalmologists solve these difficult questions by simply dedi- cating a day or two every so often to working in a free clinic. Third, the ophthalmologist can refer an unin- sured patient to a free clinic or to another practice more likely to offer pro bono services or perhaps to a practice affiliated with a medical school where considerable amounts of free care are often provided. Ultimately, I don't see how one can persuasively argue that physi- cians have a binding ethical obliga- tion to continue treatment of uninsured, non-emergent patients, despite the fact that sending them away might be heartbreaking. Of course, the ophthalmologist is ethi- cally, as well as in some states legally, bound to inform the patient of his or her prognosis with or with- out treatment. But as long as we continue to have a healthcare "mar- ketplace," obligating physicians to assume significant financial loss in the name of providing free care sounds totally unreasonable. EW Editors' note: Dr. Banja is a medical ethicist, Emory University, Atlanta, and the public member of the ASCRS Governing Board. Contact information Banja: jbanja@emory.edu

Articles in this issue

Links on this page

Archives of this issue

view archives of Eyeworld - JUN 2012