The Case of Beth: Is More Better in Oncology?
Ethical analysis is not limited to a personal ethic. Because groups and institutions are organized to effect actions that lay beyond the capacities of individuals, there must be an ethic of such entities. Then, too, society at large has its ethic and we are often bound to stretch our moral imagination to encompass a larger picture from what is good for a single person or even an institution.
More Is Better
Beth, a forty-four-year-old divorced mother of two teenagers has been diagnosed with metastatic breast cancer. For two years she has undergone two courses of chemotherapy with radiation which appears to have slowed the progress of the cancer. But during her last visit to her oncologist, she is told that the symptoms are recurring and the metastases have appeared in the lungs. The oncologist suggests she undergo autologous stem cell transplantation which involves the following steps:
When Beth hears that her insurer will not pay for the procedure and that the medical center will only perform this procedure on women if the patient's third-party payor agrees to cover it, Beth asks the ethics committee to review the hospital's institutional policy.
Questions to consider in this case study:
A personal ethic can differ from an institutional and a social ethic in the principles used, the values at stake, the possible conflicts, and the consequences of the actions done or omitted. If this were simply a case of Beth and experimental treatment, the analysis would be based on beneficence and autonomy, the values of her possibly having more time to spend with her children balanced against the debilitating effects of the treatment itself. But this is no longer simply a case about Beth. Once insurance is denied, the case becomes an issue for the providers, the hospital, even society itself.
Ethics does not tell us what is right and wrong in this case. Ethics never does. But what "doing ethics" means is that we address all the issues that impinge on a situation, personally, corporately, and socially. Today's health care is not the health care delivery system of twenty years ago.
If Beth wants the suggested near-lethal-dose treatment, not just for her own well-being but in order to have more time to spend with her children, then her autonomy and the value of beneficence form the framework for her position.
When insurance companies deny coverage, we face new values: justified (or unjustified) allocation of scarce resources (money). Physicians' groups and hospitals must face the possibility of nonreimbursable care. New conflicts arise as a personal ethic clashes with an institutional/social ethic. Before the clash between personal autonomy and institutional justice can be resolved, a number of policies should be already in place and should be subject to review. Both Beth and the oncologist must have as up-to-date overview of relevant studies as are available. The physician's group should have agreed on the cutoff point between experimental and established treatments. So, too, the hospital should have policies in place delineating how much charity care is financially feasible.
Likewise, all of us should continually reassess when further treatment should be refused and death be permitted.