A 67-year-old man is being evaluated in your radiation oncology clinic for treatment of a solid tumor. Your hospital has just purchased a new proton beam purported to deliver targeted radiation with fewer side effects than traditional radiation therapy. The patient expresses strong interest in receiving proton beam therapy, and you feel that he may have a better outcome with this new treatment modality. Later that day, an executive from the patient’s insurance company calls to tell you that proton beam therapy will cost the company (but not the patient) a much larger amount of money than traditional therapy. They are willing to pay for proton beam therapy, but request that you convince the patient to undergo traditional therapy instead. You have a longstanding relationship with this insurance company as well as this particular executive. How should you proceed?
- Discuss the issue of cost to the insurer with your patient, pointing out that keeping his insurance company happy may make them more likely to cover additional treatments in the future
- Proceed with proton beam therapy as discussed at your patient’s appointment
- Tell the patient that proton beam therapy will not be covered by his insurance company, so you will need to proceed with traditional radiation therapy
- Discuss the issue of cost to the insurer with your patient, relaying the company’s request to him without making further commentary or recommendation
- Call your hospital’s ethics committee for a formal consultation
You should proceed with proton beam therapy. When making a decision between different treatments, patient medical need and preference should take precedence over cost of a procedure to an insurer.
The ethical principles of autonomy and beneficence govern the tension between patient’s medical need and insurer’s desire to minimize costs. As a physician, you are obligated to respect your patient’s autonomy by respecting his preferences in medical care, and to respect the core principle of beneficence by acting in his best interest. In this case, there is no conflict between autonomy and beneficence - you feel that proton beam therapy is best for his condition, and he desires it. Cost to the insurer should not enter the equation, and you as a physician should not ration care to patients based on the cost of treatment. As clinicians, our responsibility is to do whatever is in the best interest of our patient’s welfare.
Gillon discusses the practical application of the four ethical principles of autonomy, beneficence, non-maleficence, and justice to patients. He states that attention to these four principles, along with a focus on their scope of application, enables successful evaluation of most health care-related moral issues.
Illustration A shows the four core principles of medical ethics: autonomy, justice, beneficence, and non-maleficence.