AMA Journal of Ethics^®

Case

Dr. Benson is a primary care physician practicing in a town of 5000 people. He often manages patients with complex medical issues and prides himself on his ability to stay current on advances in medical treatment. Each year he exceeds his continuing medical education (CME) requirements, is well respected among his colleagues, and is often consulted by other physicians for difficult cases.

Last week Dr. Benson received a troubling phone call from Sandy, the mother of one of his patients. He has known the patient, Carla, since she was a child. She was always what he thought of privately as a "difficult" patient, and during her adolescence he spent a great deal of time helping her through a substance abuse problem and a bout of major depression. Carla is now 24. Sandy called Dr. Benson to tell him that Carla's behavior had grown increasingly erratic over the past several weeks; she lost her apartment and moved back home, has maxed-out her credit cards, and does not seem to be sleeping more than 2 or 3 hours a night. Following the conversation with her mother, Dr. Benson asked Carla to come in and visit with him. Dr. Benson suspected that Carla was abusing drugs again, but acknowledged that she could have a psychiatric disorder.

After talking with Carla, who insists that she has been "clean" for several years, performing a thorough physical exam, ordering lab work, and asking Carla to consent to a urine drug screen, Dr. Benson thinks he is seeing an acute manic episode. Dr. Benson gets Carla's permission to have her mother come in from the waiting room so they can all discuss the diagnosis.

With Sandy present he explains what he believes to be the diagnosis, but says that a definitive diagnosis for such a serious disorder should be made by a psychiatrist.

"Where do we have to go to see a psychiatrist?" Carla's mother asks.

Dr. Benson explains that the nearest one is in the city, 100 miles away.

"We can't get there." Sandy cries. "The car broke last week and we don't have any money to fix it, and nobody's going to drive Carla 100 miles for a doctor's appointment. Can't you just give her something?"

Dr. Benson hesitates. He has managed patients with bipolar disorder who were sent to him already stabilized on their medications, but he has never diagnosed and started a patient such as this on a new regimen, and, moreover, he does not track the constantly changing literature in psychiatry and neuropharmacology. He also knows that, even if Carla sees a psychiatrist in the city for a diagnosis, she will not be able to make the long trip on a regular basis for follow-up appointments.

Commentary 1

Deborah Tannen, a sociolinguist, writes about the "Heinz dilemma," a hypothetical scenario used to evaluate developmental stages of moral reasoning.¹ In the scenario, a man's wife is dying, but he can save her life by stealing a drug that he cannot afford to buy from a pharmacy. The question—should he steal the drug?—is posed to 2 children. The 2 address the dilemma in very different ways—1 concludes that it may be okay to steal the drug and offers a rationale based on rules and rights. This child states that the man should steal because, even though stealing is wrong, letting someone die a preventable death is even more wrong, and thus stealing can be justified in this setting. The second child answers by trying to accommodate the man's needs without requiring dishonesty. Maybe the pharmacist could help the man, for example, or maybe the husband could pay the pharmacist back at a later date, and so on.

Intuitive reactions to the dilemma that Dr. Benson faces may be close to 1 of these 2 paths of moral resolution. Some may argue that the physician should treat the patient while others may argue that to do so without specific psychiatric consultation or support would be unwise and that there must be other ways around the immediate predicament the physician faces.

Regardless of the path one chooses, the dilemma that Dr. Benson faces should be familiar to many physicians. Although it may seem unlikely that patients' access to care can be limited by geographic boundaries, such barriers are ubiquitous and unavoidable, in the United States and elsewhere.² In fact, outside of urban areas in developed countries, where other barriers to care are prevalent, difficulty accessing specialists and medical technologies may be the rule, rather than the exception. And in some ways, the predicament faced by Dr. Benson is quite similar to other situations physicians routinely face. On the one hand, there is the aspirational ethic to treat all patients with an equally high standard of care. On the other hand, such a goal may at times conflict with physicians' responsibility to be wise stewards of societal resources³ or with financial constraints placed on patients and physicians.⁴

How then should physicians, in general, and Dr. Benson, in particular, navigate situations where a patient needs treatment that is not readily available? Answers to several clinical questions can help guide a physician through this process. First, what is the incremental benefit of the optimal treatment over the one that is more readily available? In this case, how likely is it that a psychiatrist's evaluation would yield a different conclusion than Dr. Benson's? Second, what steps can be taken to narrow the gap between the likely safety and efficacy of the optimal and that of the second-best treatments? Might a phone consultation, for example, provide a minimally acceptable means for obtaining a psychiatric consultation? Third, how comfortable are Dr. Benson and the patient with the anticipated plan of care? Given that Dr. Benson is "well-respected among his colleagues," it is likely that he has the clinical acumen to help assess the probable incremental benefit of optimal treatment over the one he can provide. Principles of informed consent, important in any setting, become especially powerful where there are "tough calls," such as whether a marginally more risky management approach is acceptable because of its greater feasibility. Finally, a less clinical question: how much additional effort is required to obtain the first-line therapy? In this case, 10 miles versus 100 miles versus 1000 miles may make a big difference.

Arguing that physicians should never stray from optimal care creates a world of moral idealism divorced from clinical reality—a reality that for many precludes access to state-of-the-art specialists and medical facilities. Just as a t-shirt may be used as a tourniquet, or a stick as a splint, physicians and patients may be required to decide whether or not an available therapy is good enough. This case provides an extreme example. However, in more subtle ways, physicians do so all the time—rationing, by any other name...⁵