AMA Journal of Ethics^®

Case

The waiting room is packed at the Urgent and Family Care office. Dr. Garrison picks up the chart for the next patient, Mrs. Williams, who has come in because of cough, fever, and chills.

"Good morning Mrs. Williams, I'm Dr. Garrison, how can I help you?"

Mrs. Williams looks older than the 50 years listed on her chart, and Dr. Garrison is struck by how gaunt and pale she appears. Mrs. Williams reports that she has had no serious illnesses or surgeries but admits that she has been a 2-packs-per-day smoker for the past 30 years.

After performing a physician exam, Dr. Garrison tells Mrs. Williams that she would like to order a chest x-ray and a complete blood count because she is concerned about the possibility of pneumonia.

"Pneumonia? Again? I've had that 2 times in the last year." Mrs. Williams exclaims.

Dr. Garrison flips back through her chart and sees that Mrs. Williams was treated for pneumonia in their office 4 months ago. Dr. Garrison orders the chest x-ray and the labs and reviews Mrs. Williams' previous films. She sees an abnormal area in the right middle lobe. In the previous film it had been read as "anatomic variant, likely related to pectus excavatum," with an infiltrate distally. Today's results show that the distal infiltrate is gone, but the area originally read as "anatomic variant" appears larger and more defined. Mrs. Williams' white count is in the high normal range. Given the patient's smoking history, Dr. Garrison is concerned about the possibility of a mass. Could this be lung cancer or is it just another pneumonia?

"Mrs. Williams, I was just comparing your chest x-ray to the one you had before in our office. I am concerned about an area that just doesn't look right to me. It could be that you have pneumonia again in an area of your lung that is a little abnormal and prone to getting infections. I'm going to treat you with antibiotics, but, given your smoking history, I'm also worried, honestly, about the possibility of a cancer. I'd like to do a CT scan of your chest, so we can get a better idea of what's there."

Mrs. Williams is silent for about a minute. "Dr. Garrison, I've thought about lung cancer because my cousin just died of that, and he smoked a lot too. But I don't have any health insurance. I just started a new job and I'll be eligible for health insurance in 6 weeks. I started in the middle of the month, and they don't count part of a month when they figure eligibility for benefits. So in 6 weeks, I'll see which plan I can afford to be in. I don't know what my rate will be when they find out that I smoke. So, can we wait to get the CT scan until after I have insurance? My cousin didn't have insurance and their family went bankrupt paying for his treatments. Now he's dead and his wife and kids got nothing. I don't want to do that to my family. Plus, you said it could just be another bout of pneumonia."

Commentary 1

Physicians must balance their ethical obligations to patients with those to society at large. Society trusts the profession of medicine to self-regulate the care it delivers, but it has strict rules for reimbursement of that care, especially when it comes to caring for those who are unable to pay. Physicians work within those reimbursement rules, attempting to meet patients' needs and preferences whenever possible. But what if society's rules are unjust? What then is the physician's obligation? These ethical dilemmas frame the problem confronted by Mrs. Williams and Dr. Garrison.

Ethically, Dr. Garrison cannot simply blame our US health care system, which seems to accept as inevitable 43 million uninsured patients, and leave Mrs. Williams to fend for herself.¹ Instead, she must advocate for Mrs. Williams and help her navigate through the barriers to her care.

All patients, and especially those who are seriously ill, need health care professionals whom they trust to guide them through our complex system and to assist them with the difficult decisions they face. In this case, Mrs. Williams has been seen in the practice before, but not by Dr. Garrison. I will resist the temptation here to comment on the decline in continuity of care. Focusing on the situation at hand, Dr. Garrison should discuss with Mrs. Williams which doctor in the practice she would prefer to see for her subsequent care.

What else should Dr. Garrison try to accomplish during this initial visit? The answer is not much. Mrs. Williams has just received shocking news: she might have lung cancer. She knows full well the potential horror of the disease—she has witnessed the tragedy of her cousin and his family. When confronted with such devastating news, rational thought typically takes flight and is replaced by confusion and denial. This is not the time to discuss rationally Mrs. Williams' request to wait 6 weeks before further testing.

Dr. Garrison's best strategy is to schedule a follow-up visit in 1 to 3 days with Mrs. Williams' doctor of choice. She should encourage Mrs. Williams to bring a trusted friend or family member to that visit. The simple act of deciding which doctor she will see and identifying a support person can help Mrs. Williams reestablish some control over her life, control that was lost moments earlier when the possibility of cancer was mentioned. Dr. Garrison should then conclude this initial visit as empathically as possible.

The doctor that Mrs. Williams chooses must carefully plan the next appointment. A well-structured visit with information regarding her options for determining a definitive diagnosis will help give Mrs. Williams the confidence that she will need to deal with her health crisis. It should begin with the doctor's asking what thoughts she has had since the last time she was at the office. If Mrs. Williams remains focused on financial concerns and reiterates her request to wait 6 weeks until she has insurance before pursuing any further diagnostic tests, the doctor must gently outline the problems with this approach:

• The insurance delay will probably be longer than 6 weeks. It is unlikely that Mrs. Williams will be able to sign up, on day 1 of her eligibility, for a plan that will immediately cover a CT scan of her chest. Realistically, as much as 4 to 8 weeks should be added to her estimated 6-week delay.
• The insurance company will most likely consider this a pre-existing condition. Even though Mrs. Williams does not have a definitive diagnosis, she does have symptoms and objective x-ray findings that point to a possible neoplasm. Thus, waiting may not achieve the desired result of having her tests and treatments covered.
• Any delay in the diagnosis and treatment of lung cancer may affect the treatment outcome. Delaying 6 weeks or longer could decrease the chances of a cure if the suspicious area turns out to be cancer.

Given that the risks involved in waiting are great and the benefits uncertain, the doctor should advise Mrs. Williams to proceed with the CT of her chest. Psychologically, patients deal better with known problems than with uncertain fears. So, even if the CT scan confirms that Mrs. Williams has a lung cancer, the conclusive diagnosis will take her out of limbo and allow her to begin to deal with her cancer. I would recommend that the physician schedule the CT scan before Mrs. Williams returns for her follow-up—within 48 hours of the initial visit, if possible—so that she can say to Mrs. Williams, "I took the liberty of making you an appointment for tomorrow. It can be cancelled or postponed, but I wanted to give you the option of immediate care." This paternalistic approach can be justified in times of crisis but must be judiciously balanced with efforts to empower the patient's own decision making so that she can regain a sense of control.

Anticipating that Mrs. Williams might ask, the doctor should know the approximate cost of a chest CT ($850-$900 for scan and radiologist's interpretation at my institution) and be able to direct her to the hospital's financial counselor or other community resource to help resolve some of her financial concerns. The doctor could also offer to make this appointment for Mrs. Williams.

A timely follow-up appointment should be scheduled to review the CT results and to discuss options with the doctor. At some point, the doctor should address end-of-life issues with the patient. The recent Schiavo case emphasizes the importance of discussing advance directives regardless of the test results. Because it is difficult to prognosticate without an accurate diagnosis, a tissue biopsy is typically necessary before Mrs. Williams and her physician can have a serious discussion about the risks and benefits of the various treatment options. Should the tests confirm cancer, and depending on her prognosis and personal values and beliefs, Mrs. Williams might choose palliative care over aggressive curative care. Shamefully for this country, her lack of insurance may influence that decision.

The physician will face an unfortunate dilemma if Mrs. Williams insists on waiting until she has insurance. The insurance company may contact the practice and ask if there is evidence that this was a pre-existing condition. Physicians must respond truthfully to such direct questions; to do otherwise is unethical and constitutes insurance fraud.

How forthcoming should the doctor be if the insurance company does not ask direct questions? Suppose Mrs. Williams asks the doctor for advice on how she might get around the pre-existing condition clause in her insurance coverage? The central point of this commentary is that ethical physicians should advocate for their patients and help them negotiate the health care system. To what lengths individual physicians are willing to take their advocacy depends, in part, on how fair they think our current system is. America stands alone among industrialized nations in its failure to ensure that all its citizens receive basic health care. I believe that it is unjust to limit access to care for 43 million Americans because of their inability to pay. Therefore, I would do all that I could legally and ethically do to help Mrs. Williams obtain access to care—access that should be her right.