Virtual Mentor. April 2000, Volume 2, Number 4.

Cases in Law and Ethics

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Intentional Misdiagnosis to Get Insurance Coverage

An ethical case explores what a physician should do when a patient's health insurance will not cover a screening test for cancer despite the fact that a family history puts the patient at increased risk of developing the disease.

Both ethics and law address norms that govern physicians' behavior. Many view the law as a baseline for articulating the limits placed on individuals living within society as well as an enabling device to facilitate social relationships. Encompassing as the law may be in some areas of human conduct, in many others it is silent. In the absence of legal norms or prohibitions, physicians often find guidance in the standards arrived at through ethical reasoning.

To guide students through the process of ethical reasoning and to acquaint them with case law, a new case study will appear every 2 to 4 weeks. Students will be given legal and/or ethical opinions to assist their decision-making.

April Case Scenario

A 32-year-old man presents with no significant past medical history. The patient's 38-year-old brother was recently diagnosed with colon cancer and recently underwent a subtotal colectomy. Given the young age of his brother, the patient is now concerned about getting (or already having) colon cancer. Although he has no abdominal symptoms, he insists on a screening colonoscopy. The physician shares the patient's concern and believes that given his family history such an intervention is warrented. However, the patient's health insurance plan will not pay for a colonscopy, but the physician knows that the plan will pay if the patient has had recent weight loss and change in bowel habits, although this diagnosis is inaccurate.

What should the physician do?

For more information relevant to this case, see AMA Code of Medical Ethics, Opinion E-8.12, Opinion E-8.13, and Principles of Medical Ethics.

Related Articles

• Freeman VG, Rathore SS, Weinfurt KP, et al. Lying for patients: physician deception of third-party payers. Arch Intern Med. 1999;159:2263-2270. Article available at: Archives of Internal Medicine. Accessed March 17, 2000.
• Cain JM. Is deception for reimbursement in obstetrics and gynecology justified? Obstet Gynecol. 1993;82:475-478. Abstract of article available at: MEDLINE. Accessed March 20, 2000.
• Rost K, Smith R, Matthews DB, Guise B. The deliberate misdiagnosis of major depression in primary care. Arch Fam Med. 1994;3:333-337. Abstract of article available at: MEDLINE. Accessed March 20, 2000.
• Menzel PT. Economic competition in health care: a moral assessment. J Med Philos. 1987;12:63-84. Abstract of article available at: MEDLINE. Accessed March 20, 2000.
• Morreim EH. Fiscal scarcity and the inevitability of bedside budget balancing. Arch Intern Med. 1989;149:1012-1015. Abstract of article available at: MEDLINE. Accessed March 20, 2000.
• Daniels N. The ideal advocate and limited resources. Theor Med. 1987;8:69-80. Abstract of article available at: MEDLINE. Accessed March 20, 2000.
• Brody H, Bonham VL, Jr. Gag rules and trade secrets in managed care contracts: ethical and legal concerns. Arch Intern Med. 1997;157:2037-2043. Abstract of article available at: MEDLINE