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HEALTH ETHICS TODAY
Volume 10, Number 1, August 1999
Case: Beyond Standard
Medical Treatment
A patient arrived in the emergency department of a city hospital in
an anemic condition. He had been transferred from a smaller rural centre
where he had been suffering from a bleeding ulcer for a number of weeks
and where efforts to mitigate this problem had not succeeded. The ER
physician wanted to give the patient a blood transfusion to build up
his red blood cells and counter the anemia. The patient refused the
treatment, saying that he was a Jehovah's Witness and that his religious
beliefs would not allow him to accept a blood transfusion.
The patient had family within the city. His sister was currently
unemployed, having just recently been laid off from a secretarial job.
His parents also lived in the city, but they too had little or no income,
and in addition, a fair degree of ill health. The patient's sister
was living with them and helping to support them.
Upon consultation with the family and learning of their absolute
refusal to accept a blood transfusion, the ER physician was left with
few alternatives. After some consultation with other physicians and
the pharmacy department, he found that there was a drug used with HIV
and renal dialysis patients that stimulated red blood cell production
and that might be helpful for this patient. But the drug was expensive,
and it was not carried in the hospital's formulary. The nearest source
for the drug was from another city, and there would be significant
costs in having the drug shipped to the hospital in a timely manner.
In addition to the logistics and cost issues, there was also the
issue of whether this treatment was covered under the Canada Health
Act. Hospitals generally cover the cost of treatments that are considered
standard or basic, but they may charge for treatments that are considered
above and beyond basic care. For example, if a patient with a broken
leg wishes to have a fibreglass cast rather than a plaster cast, a
hospital may charge for the difference between the plaster and fibreglass
cast. This is because the fibreglass cast is considered as something
beyond basic care, whereas the plaster cast is standard.
It was decided to discuss the issue with the patient. A proposal
was made to the patient and his family to use the drug, but that a
charge of between $600 and $700 would be billed to the patient to cover
the costs involved. The justification for this was that it was beyond
the standard treatment, which would have been a blood transfusion.
The family was not happy about this solution but eventually agreed
to accept the charge.
The drug arrived, it was administered to the patient, and he began
to recover. However, when the bill was mailed to him, his sister came
into the hospital and informed the finance department that she would
not pay the bill and that the family had felt coerced at the time that
they had agreed to pay for the costs. In addition, they also felt that
this kind of expense should be covered by the Canada Health Act, and
that just because they wanted an alternative form of treatment, that
should not be reason to have this use of the drug considered as something
outside the scope of services offered under the legislation. (The drug
is covered under the Canada Health Act when used with renal dialysis
or HIV patients).
The problem was passed on to a hospital administrator. Rather than
dealing with the ethical issues involved, the administrator attempted
to find a solution which would relieve the family of the cost burden
and not compromise the earlier decisions to get the drug and to charge
the patient. The hospital foundation was approached to see if they
had money under patient comfort funds and whether that money could
be used in this circumstance. It turned out that there were funds available
that had recently been donated by a service club that had folded its
business and had given the foundation money that could be used for
any purpose deemed acceptable by the hospital. But when the administrator
went back to the finance department to inform them that the foundation
would pay the bill, he discovered that the family had returned and
had paid the bill in full. There were rumors that the elders of their
church had raised the money within the congregation.
Despite the bill being paid, the administrator felt unhappy with
the way events had unfolded. Even though the matter was settled, he
took this issue to the hospital ethics committee to have it discussed
so that if a similar situation were to arise in the future there would
be ethical guidelines in place. The ethics committee, however, agreed
with the original decision to charge the patient. Their argument was
that society as a whole shouldn't have to pay for the preferences of
a minority group that would not accept standard clinical practice because
of religious beliefs. Individual preferences might warrant a fibreglass
cast, the committee reasoned, but that did not justify the rest of
the community paying for such a cast when a plaster cast worked much
more cheaply and just as well for the setting of bones. The case was
the same, the committee felt, for the blood additive and blood transfusions.
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