The Cost of Ethics

I want to share a story I’ve seen at work. A lady in her early fifties had come over from Indonesia to see her family. She did not have travel insurance, because she had COPD (a type of chronic lung disease) and it would have been expensive. She brought along some of her own oxygen (which she only needed for emergencies) and her medications. Unfortunately, while she was in the UK she began to deteriorate – people with COPD commonly get lung infections, or ‘exacerbations’. These commonly can be treated in the community but more severe episodes require a short hospital stay with nebulisers, steroids and antibiotics to recover. Very severe exacerbations are life-threatening, especially in the frail, but in general most get better within a few days.

Anyway – the story. She attended hospital acutely short of breath and was seen in A&E, given initial treatment, and flagged up as a foreign national who was not entitled to free healthcare. In the morning she was informed of this, with the help of a translator, along with the recommended medical plan to stay in hospital for 2-3 days to recover with the help of nebulisers etc. She refused to stay despite the best efforts of the medical registrar on-call to convince her to, on account that she did not want to (or could not afford to – it is unclear) pay for treatment, and left to be with her family.

Two days later she came back in, substantially more unwell. She was started on treatment again, with IV antibiotics this time, and for a while she looked better. She went up to the ward around lunchtime.

Two hours later, I hang up on the on-call neurology consultant as my bleep screams out a crash call. She is peri-arrest, unresponsive, with one of the worst blood gas results I have ever seen. ITU are involved, she is intubated, ventilated and moved to the unit.

Three things:

1) I knew perfectly well that if she wasn’t able to pay for treatment on AMU, she sure as hell wasn’t going to be able to pay for treatment on ITU (costs being well above £1000 a day). Did I hesitate for a moment, contemplating this, before she was intubated? Of course not – a person was dying in front of me. What kind of person would I be if I let her die because of money? I’d be a monster. Did anyone else hesitate? No. Would you?

2) Ultimately, and somewhat ironically, this lady is going to cost the NHS significantly more as a direct result of telling her she had to pay for treatment. Realistically, the NHS is not going to recoup its costs from this woman, if she survives. If it hadn’t been attempted, in all likelihood she would have been in AMU for 2-3 days and that would have been that. The thing that really struck me about this case in the feeling of culpability, that the very fact that money was asked for precipitated the chain of events leading to her being intubated on intensive care.

3) All of this trouble could have been avoided if she had simply paid for travel insurance.

slow_dying_flower_credit to TaylorAnnDixonImage credit – Taylor Ann Dixon ©2014

It’s difficult to see exactly what should have been done here. Clearly, the NHS cannot give out free treatment to all foreign nationals – it would be a disaster – but there needs to be some scope for emergency treatment. Equally, no human being deserving of the name is going to stand by and let someone die because their bank balance isn’t big enough. As with much of medicine, this story sits in shades of grey…what would you do, policy-wise, to try to prevent this happening again?

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6 responses to “The Cost of Ethics

      • I would have not discussed $ with the patient until the end of the hospital stay. Unfortunately, those policies are not made by the likes of you or me, they are the professional hospital bean counters. I am in the US but a case in point was a few months ago when I took my son to the local ER because of respiratory distress. After a few hours a woman showed up in the bay with a bill and after handing my son a teddy bear, handed me a piece of paper with the bill so far: over $1,700. “Would you like to pay some of this with a credit card right now?” Now, I have insurance. I also have a good income and I understood clinically just how ill he was, but I could totally see someone else getting freaked out and leaving with their child inappropriately. In the end he was transfered to the large children’s hospital for further treatment. If I hadn’t stayed, he would have died. The problem is that economics will always be at play in healthcare no matter where that care is being given. A perfect system cannot exist on this earth and that is the difficult thing about what we do as providers. We try to bridge that gap between the bean counters and humanity, sometimes unsuccessfully.

      • Agreed – that in the initial phase would have been best for her health, although people are able to argue the other way – that people should know what they are accruing in case the sum total ruins their life afterwards. Although that principle stands for things like mobile data, it’s quite a different kettle of fish when people might die.

        I’m shocked that someone would be so callous with you when your child is unwell, although not so shocked that I am unbelieving – these people are definitely out there. Cynically, for the bean counters that approach makes sense – the people most likely to be freaked out are also the people who are least likely to be able to pay. Not good for health, but good for the bank.

        I’m grateful that I work in a healthcare system where I have never had to worry about the financial cost of an intervention or investigation to my patients, and hopefully never will. I don’t know how it works in the US – when someone is unable to pay, or their health insurance caps out, what do you as the doctor end up doing?

      • I get creative. I down code the severity of visits and give discounts for cash payers. I send my diabetics to a grocery store that can do A1C and lipid checks and vaccinations cheaper than I can offer them. Those patients always remind me that there are a lot of things we do as physicians because we CAN, not because they are necessary. There is a lot of waste in the system. As for the teddy bear bill woman, it wasn’t her fault. She was just trying to make a paycheck and carry out the policies of the bean counters. It was an expensive bear, though…,

  1. It’s interesting seeing your side of things – here we try to make the most of every admission as money is paid to the hospital from the government based on a complex series of tariffs (some of which heavily under-pay e.g. thoracoabdominal aneurysm repairs). As such we are constantly hounded to ensure that we document every tiny thing on the discharge summary – did this patient get constipated, were they offered smoking cessation – to try to maximise the tariff.* Tariffs that over-pay have to cover deficits elsewhere e.g. A&E. On the other side of the pond where the patient pays you try to minimise it…same job with a completely different view on the bottom line.

    *although of course ‘maximising the tariff’ never goes as far as requesting additional investigations etc as ultimately that is cost in the system.

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