The Case of Ophelia: Conflicting Values in the Placement of Violent Teenager with Mental Disability 

Case prepared by Rosemary Hanigan, PhD, director of ethics committee education, Midwest Bioethics Center

 

Ophelia is fifteen years old, nearly six feet tall, and weighs 160 pounds. She is severely retarded and has a history of violence against others. Ophelia's mother was addicted to crack and she abandoned Ophelia when the child was five years old. The mother has refused to have anything to do with her daughter since that time. For several years Ophelia was in and out of foster homes, but when she was twelve, a foster home could not be found for her, which was due in no small part because she was becoming violent. Because State A in which Ophelia resided, had no mental facility with room for an adolescent girl, state officials sent her to a large mental facility, which has approximately 150 residents in State B. Her care has been paid for by State A's Medicaid.

In the intervening five years, State A enrolled Ophelia into Hope Care, a managed care plan for Medicaid recipients. Tom X is the executive in charge of case management at the plan and he finds it abhorrent that Ophelia is in a facility outside the state. He indicates that Ophelia should be "brought home." Ophelia's case manager, Mary Lou P., agrees.  She thinks that "even in the worst cases" children can be placed in foster homes and that "normalization" is the most important value. She is confident that a family can be found.  Moreover, with training, the necessary support services, and respite for the foster parents, Ophelia can have the "real home she deserves” Mary Lou says.

To further complicate matters, State A has decided that it wants Medicaid money spent in its own state and has mandated that all patients out of state be brought home within the next twelve months.

The CEO of the plan, George O., believes there are approximately forty Hope Care members in similar situations for which the plan is responsible. He believes it will be impossible to place these children in foster homes and that, even if forty such families could be found, the cost would be prohibitive. He argues that in Ophelia's case, her IQ is so low that she has no interest in family and that she is a danger to others. Further, George O. makes it plain that by expending such significant resources on a small number of members, he may jeopardize the care of other children in the plan.

This has become a very heated issue within the management team. Tom X has threatened to quit if George O. refuses to "do the right thing." Hope Care has an ethics committee and the two men agree to take the issue to the committee.                        ·                                                            ·

 

Case Commentary and Questions

This is an excellent case for members of an ethics committee to role play. Assign the cast of characters before the meeting begins so they can begin to assume their roles. The committee chair meets Tom X and George O and brings them into the room, introducing them to committee members. Each man is encouraged to tell his story as he sees it.

Questions for the committee to consider:

1)  What conflicts of values are present in this case? Name the conflicts and the conflicting values (e.g., are there conflicting meanings of beneficence at work here?)

2) Take one of the conflicts for your consideration. Fill in all missing facts by asking questions of Tom and George (e.g., Has any expert opinion been given about the girl's present state, including her propensity for violence? Is there space available in any of State Ns institutions for Ophelia? For the others?)

3) As you argue for one value to take precedence over the other, you will have practice in seeing the effects your argument has on the two characters. What kind of argument do you make when you place one value in priority over another?  Have you justified your priority ranking without diminishing the dignity of the one whose value was not chosen?

4) If time permits, take another conflict; have two other members of the committee assume the roles.

5) Proceed as before.

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