Reference no: EM133181032

Metropolis hospital is facing mounting deficits due to reduced medicare reimbursements, new guidelines and parameters from HMO's, and increased costs associated with new medical technology. The deficits put the entire hospital at risk of closing.

Through city and state contracts, metropolis gets reimbursed for a certain number of indigent patients (those with out health insurance and without means to pay for treatment) it treats. There are laws which require the hospital to accept patients who present themselves with a genuine medical emergency. 

Madge, an African-American, arrives at the emergency room of Metropolis. She is 78 and complains of chest pains. After an extensive examination, she is diagnosed with a cancerous tumor in her lung. Madge also appears to have emphysema - probably caused by her smoking.

Recommended treatment includes:

• Removal of the tumor - with follow-up chemotherapy
• Chemotherapy alone

The prognosis for someone of her age, condition and past history of smoking is only a 10-20% chance of surviving five years. The difference in removing the tumor through surgery with follow-up chemotherapy only increases the five-year survival rate by 5% (15-20%).

Chemotherapy alone is much less expensive. Dr. Ken argues that Madge only has medicare - and that medicare will not adequately compensate the hospital. The state and city indigent care amounts have already been exhausted. He believes that since her prognosis is bad either way - scarce hospital resources should be diverted to those with a better chance or recovery and long-term life. He recommends chemo alone.

Dr. Karen argues that Madge is already socio-economically disadvantaged. She is black and has suffered discrimination and less-than-equal earning opportunities. Why should she continue to get less-than-optimal care? She recommends surgical removal of the tumor and chemo.

Nurse Juan argues that it is her decision. She is a human being with the right to make health care decisions. We have an obligation to honor her decisions. 

Nurse Martha argues that Madge may have a right to make a decision - but she has no right to waste scarce medical resources. She argues against surgical removal and proposes chemo alone.

Lee, a nurse practitioner, argues that the decision is not a matter of using/not using limited resources - but asking what is in the best advantage of Madge. Will the surgical removal of the tumor actually cause her more harm and risk with very little hoped-for advantage? 

The risk-management team raises issues of potential lawsuit if she is not treated and an advocate or lawyer files suit that she was discriminated against. The risk management team argues that although surgery is more expensive than chemo alone - it is less expensive than a protracted lawsuit. They argue that even if surgery and chemo is more harmful and produces no extra benefits - it is better to err on the side of over treatment than risking a lawsuit for undertreatment.

• Identify types of justice/ethical arguments laid out by the various members of the team.
• Which do you think has the most merit and why?
• In health care situations - is there a preferred justice approach?  Why?
• What are the competing obligations/values/interests in this case?