SHOULD THE FUNDING SOURCE PLAY A PART IN THE ALLOCATION OF RESOURCES?
The healthcare facility was experiencing a high census and as a result was out of labor/delivery/recovery/postpartum rooms, necessitating some patients be moved to smaller rooms in the pediatric unit according to the facility's protocol. One family that was approached refused to be moved, and an altercation occurred, causing the charge nurse significant distress. The charge nurse in the birthing center approached the department head for advice regarding the allocation of resources.
The department head was somewhat confused by the inquiry, because there were numerous other patients that could be approached. When questioned, the charge nurse indicated that the alternate families had insurance and were "paying" clients of the facility, whereas the first family approached was without resources other than Medicaid. The nurse felt that those who were not paying for their healthcare through either their own resources or insurance should not be able to refuse reasonable requests regarding the allocation of facilities.
When advised by the department head that the source of payment, if any, was irrelevant, the charge nurse continued to defend her position and maintained that those who paid had more "rights" than those who did not.
QUESTION
Should the source of payment be a factor in determining the facility available?
DISCUSSION
Allocation of scarce resources is something that healthcare providers around the world struggle with on a daily basis. Whether determining which children get malaria medication in a South American jungle, which person gets a heart/lung/kidney available for transplant, or how to allocate the use of ventilators in the event of an influenza pandemic, the issue has been studied and policies issued by most every facility. Each of those policies, in turn, tends to follow the politically correct (and legally supportable) position that, at least for those healthcare treatments necessary to safeguard life, no discrimination should occur between those who have resources to pay for medical treatment as opposed to those who are without resources.
Should that decision, however, be extended to relate to nonessential issues associated with healthcare? In the example listed above, let's assume that the rooms are identical other than size. The nursing staff, medication, food, and all other aspects of the facility are identical, so no harm will come to the patient or the patient's family if they are moved to a different room.
Is there harm in forcing them to move? Do we create a group of "second-class citizens" by relegating them to the less desirable locations when allocating resources of this type? No one would argue that identical water fountains, directly opposite each other in the same location, but labeled "colored" and "white" is unconscionable. By relegating those individuals without resources to smaller rooms in less desirable locations, are we committing that same act? Or is the facility instead simply using the same rules that apply on a cruise ship, where the food and use of amenities tends to be equivalent, but the cost differential is based solely on cabin size?
A deeper question involves why the charge nurse even knows anything about how a patient is going to take care of the charges for their services. Certainly, nursing is a very personal act, and patients and their families share information about a variety of things other than those solely associated with treatment. Given the impact of healthcare costs on most families, it is not at all difficult to believe that the topic might be discussed, either with the nurse or when she might overhear while performing legitimate healthcare duties. The information should not matter any more, however, than information similarly received about a patient's marital status, religious beliefs, or sexual orientation. It has no bearing on the healthcare process, and the nurse should make decisions regarding the administration of the department without regard to payment sources of any particular patient.
In this example, the nurse presumably had other nondiscriminatory choices that she could make. Because the census is high, she could ask other patients about their willingness to move. If no family were willing to move, it would then be appropriate to review the facility's policies to determine the appropriate procedure. If the issue is not addressed by the facility's policies, then a decision should be made based on criteria that have legitimate relationships to the reasons for the moves. A large family that has just had twins, for example, may legitimately need a larger room than a couple with no immediate family in the area. Special healthcare needs may require placement in a location that is more convenient to the attending healthcare providers to allow more frequent nursing attention. Locational decisions that are based on legitimate medical care criteria are certainly appropriate to use in deciding placement.
From the healthcare facility's perspective, the source of payment is irrelevant. Rates have been set for services to be provided and will be billed accordingly. It matters not whether the money comes from a governmental insurance system, private insurance, personal resources, or the benevolence of the patient's family. The money used to pay for the services is all the same. If the nurse has strong feelings about Medicaid, the appropriate venue to discuss that is with the elected officials who design and administer the system.
Similar inappropriate bias arising from a healthcare provider's personal beliefs can occur when treatment is impacted because of the personal conduct of the patient. Cigarette smokers are, by this day and age, well aware of the impacts of cigarette smoking on their personal health. The dangers of a diet obtained primarily through the window of an automobile can have a substantial impact on cholesterol, diabetes, and a number of other chronic conditions. Those who engage in unprotected sex are more likely to be exposed to communicable and potentially life-threatening diseases. People make the decision every day, however, to continue with these activities despite the known risks. Under our system of government, the freedom to engage in these activities exists, and, in fact, our government frequently sanctions such activities through tobacco subsidies, zoning and planning systems that encourage increasing numbers of fast-food restaurants, and continued adherence to policies that refuse to permit distribution of educational information about safer-sex activities.
No one would argue, however, that a healthcare provider should be free to impose his/her personal beliefs on the decision as to whether to provide healthcare to a patient with lung cancer or undergoing amputation because of diabetes complications. Patient autonomy extends not only to the right to control or refuse treatment, but also to the ability to undertake activities with known risks and consequences. Our society values the individual's rights to make his/her own decisions, even when such decisions impose additional costs on society. An individual healthcare provider cannot legitimately impose his/her own system of beliefs on a patient or influence the treatment or placement of a patient, because he/she disagrees with the individual's life choices. Instead, it is through the ballot and other constitutionally guaranteed freedoms that an individual can make his/her opinions known. If sufficient others agree with that position, the system may be changed. To allow any individual other than the patient to make personal decisions about the provision of healthcare based on the source of payment though reduces healthcare access to a free-market system where services are available to the highest bidder.
The nurse manager can assist staff in exploring the issues discussed in this column by using it as the basis for a discussion on the subject.
Questions to promote discussion:
1. Is it ever appropriate to make patient-related decisions based on your personal beliefs?
2. What assumptions do you make about patients who have private insurance? Who are indigent?
3. How might those assumptions impair your ability to give good care?
4. What steps could you take to resolve a conflict between your beliefs and the care needed by a patient?
5. What policies in your facility address this issue?
Section Description
Conversations in Ethics is an open forum hosted monthly by Catawba Valley Medical Center in Hickory, North Carolina. A box lunch is provided free of charge to participants who meet to discuss a specific case that is distributed in advance. The program lasts from noon to 1:00 pm and is also open to the public. The purpose is to discuss ethical situations which confront healthcare providers and evaluate possible options and considerations available. The goal is not to provide a resolution to the situation, but rather to evaluate options available and gain perspective on common situations from various points of view. Please note that the situations presented here are fictional, although they are composites of various situations that have been encountered by the authors or other individuals providing background information or suggestions.