T.Hill_Ethics Interview Account Page | 1
NU 502- Advanced nursing practice ethics /Ethics Interview Account /
The ethical dilemma of an illegal immigrant. /
Tracy Hill /
9/14/2009 /
The purpose of this paper was to interview a person with some authority in directing ethical decision making and to discuss an example of a complex ethical situation in which he or she helped resolve and discuss factors that guided the resolution. S.D., the VP of Administration at a 173-bed community hospital was interviewed for this paper. Multiple complex ethical situations were discussed, and one particular case involving a medical ethical dilemma with an illegal immigrant became the focus of the interview. The author also discussed moral or ethical theories and framework that guide such complex decisions for ethical committees and individuals. /
The purpose of this paper was to interview a person with some authority in directing ethical decision making and to discuss an example of a complex ethical situation in which he or she helped resolve and discuss factors that guided the resolution. S.D., the VP of Administration at a 173-bed community hospital was interviewed for this paper. Multiple complex ethical situations were discussed, and one particular case involving a medical ethical dilemma with an illegal immigrant became the focus of the interview. The author also discussed moral or ethical theories and framework that guide such complex decisions for ethical committees and individuals.
For this ethics interview account, the author interviewed S.D. (personal communication, September 14, 2009), the VP of Administration at a 173-bed hospital in a northeast Kansas community with a population of around 112,000. S.D. currently serves as the VP of regional services as well as the director of the oncology and breast centers at the facility. S.D. is also a member of the ethics committee. S. D.’s education includes:Master of Science in Health Services Administration, and a Bachelor of Science, with a Certificate in Physical Therapy. S.D.’s work experience includes starting as a staff physical therapist in 1983, then promoted to Senior Physical Therapist/Assistant Clinical Coordinator at a large northeastern U.S. hospital; next, S.D. became the manager of an outpatient rehabilitation services department in the Midwest. In 1996, S.D. became the Director of Rehabilitation Services at another regional healthcare facility and in 1999 became the director of the rehabilitation services department at the current facility and most currently and concurrently as previously discussed, VP of regional services and director of the oncology and breast centers.
Typically, ethics committees assist patients, their families, caregivers, and staff by providing an impartial forum for the discussion of ethical issues and difficult treatment decisions. The committee promotes autonomy and equality for all persons (Ethics Committee Administrative Policy, Lawrence Memorial Hospital, 2006). The ethics committee also seeks to be a functional and effective resource for the hospital and the surrounding community, by increasing awareness of ethical issues and offering ongoing education and consultative assistance.
The ethics committee at this 173-bed hospital has ten members, appointed by the CEO/President of the hospital, based on recommendations forwarded by administration, medical staff and clinical services. Each voting member of the committee serves an overlapping term of four years, with no more than four of the members retiring/resigning each year. Members may also be reappointed for additional terms. According to the administrative policy for the ethics committee at this facility, members include, but are not limited to an academic ethicist, administrators, a board of trustees member, a chaplain, clinical ancillary staff, community representatives, nurses, physicians, the risk manager, and social workers. Currently, the ethics committee at this facility has two co-chairs, a chaplain and a retired OB/GYN physician. The other members of the ethics committee include: two hospitalists that rotate serving on the committee, the vice president of risk management, a registered nurse from the oncology department, a registered nurse from the palliative care team, the vice president of administration, a social worker and two laypersons: one of whom is a retired ombudsman, and the other is a professor of ethics and philosophy.
The ethics committee at this facility meets monthly and special meetings are called as needed (prn), which, according to S. D., is usually an additional three to four times a year. A quorum for regularly scheduled meetings is eight members. All records are considered confidential and minutes of the meetings are kept as an occurrence/inquiry without use of identifiers or recommendations. The ethics committee may be consulted by any concerned party, such as the medical staff, hospital staff and/or patients and their families or friends. It is important to note that the role of the ethics committee is advisory only, with final decisions left to the appropriate responsible parties. Once a request is made to consult the ethics committee, the request is reviewed and it is determined whether there is an ethical issue or whether the matter can be resolved otherwise. The ethics committee also serves as a mediating group between concerned parties if requested for significant conflict between patients, physicians, and/or the families.
The interview was prefaced with the question “Would you provide an example of a complex ethical situation that the ethics committee has faced, including the framework for the ethical analysis and the resolution of the ethical situation?” S.D. mentioned that end of life decisions are brought to the ethics committee frequently, but stated that those cases were not the difficult ones to deal with, as they usually involved distant family members showing up and disagreeing with decisions that have been made, and usually involve mediation between family members and then issues are resolved once the “long-lost” relative understands the situation more clearly.
Several case studies were discussed during this author’s personal interview with S.D., however, one particular case study was chosen by S.D. as a topic of interest for this interview account. The case was presented to the ethics committee in August, 2009, and involved “Mrs. White” (alias), who was a 36 year old illegal immigrant from Mexico, who only speaks Spanish. “Mrs. White” was referred to the oncology center by one of the OB/GYN physicians. “Mrs. White” was thirty-six weeks pregnant and newly diagnosed with idiopathic thrombocytopenia (ITP). The disease results in low platelets and the patient would be at risk for bleeding/hemorrhaging unless treated urgently (not emergent). The county health department has an agreement with the hospital regarding pregnant immigrants, in that the local OB/GYN group, owned by the hospital, will take care of the patient’s pregnancy related issues. The standard of care for treatment for ITP in this case was five doses of immunoglobulin (IGG) at nearly $5,000 per dose (cost to hospital). The manufacturer has a patient assistance program for those who qualify, but the patient must be a U.S. citizen. This was the patient’s fourth pregnancy. All of the other babies were delivered in Mexico and according to the patient (through an interpreter), all the deliveries were normal. The patient also reported that she never had any blood drawn in her life, including the previous pregnancies.
The ethics committee discussed several issues. First, if the ITP was pregnancy-induced, it should go away after the delivery, but since the patient had never been tested, it was impossible to document if this ITP was pre-existing or a new onset. If the ITP was pregnancy-related, it was part of the agreement with the local health department for coverage; however, the OB/GYN physician had no documented previous information, so they could not state whether or not it was pregnancy related. Next, the patient stated that she could not pay for the treatment. The patient’s spouse worked at McDonald’s and insurance was not provided. The ethics committee also discussed what responsibilities the oncologist, the hospital, the patient and the health department had. Finally, they discussed that Medicaid had a program for emergency-covered services for illegal immigrants; however, this situation did not fall under the “emergent” category.
In this case, the outcome for the patient, “Mrs. White”, was that she received the five doses of IGG, once a day for five days. “Mrs. White” was encouraged to have her labor induced so that closer monitoring was possible; however, the patient refused induction; Mrs. White spontaneously delivered a healthy child around thirty-eight weeks gestation; it is the author’s understanding that there were no complications for the patient or newborn. The patient was required to meet with a financial counselor to discuss payment options to the hospital, which incurred the expense of the IGG and other related expenses; the financial outcome is not known.As a side note, one possible resolution discussed by the ethics committee in regards to this ethical dilemma was whether it would be appropriate to provide a plane ticket for the patient to go back to Mexico so she could deliver her child there, since that was her native homeland and the country in which she was a resident. While it would have been “cheaper” to buy the patient a plane ticket “home” than to provide the IGG treatment, the ethics committee felt that was not an appropriate decision at the time.
The author asked S.D. to discuss the moral and ethical theories or type of framework that are used in making decisions or recommendations. S.D. stated that the committee members alwaysmake sure the following questions are answered before making final decisions: “Who is the stakeholder? What are the patient’s wishes? Is the patient competent?” S.D. also stated that the ethics committee is guided by the hospital’s Code of Ethics and Informed Consent Policy.In the hospitals Code of Ethics Policy (2004), the hospital pledges that it will interact with patients, staff and community members in an ethical manner. The policy states that the hospital will further commit to providing services in a manner that fosters dignity, autonomy, self-regard with regard to civil rights and the right to be involved in his/her care decisions (Code of Ethics, 2004). The hospital also pledges to act honestly and in a professional manner in marketing and billing efforts and services provided, and pledges to comply with all appropriate and regulatory requirements to the best of their knowledge. The Informed Consent Policy’s purpose is to clarify that the consent form provides documentation that the patient and/or person (s) responsible for the patient, has been informed regarding medical care required for treatment of their condition and have given their consent for the administration of the particular care (Informed Consent Policy, 2007). It is defined in the Informed Consent Policy that all patients must be presented with the opportunity to give an informed consent to his/her treatment, surgery, or anesthesia. This policy discusses patients, parents of minors, personal representative/surrogates, Durable Power of Attorney for Healthcare, emancipated minors, or other legally designated individuals (guardians or conservators) competent to understand the information provided and given the opportunity to consent. Great detail is taken in this document to give all possible opportunity to the patient whenever possible, and discusses/defines competence in great lengths, as well as emergency consent and minors, non-English speaking patients and verbal consent. The Informed Consent Policy also references Kansas Hospital Law in great detail (Informed Consent Policy, 2007).
In addition to following the above recommendations as outlined in the Code of Ethics andInformed Consent Policies, S.D. also stressed that the ethics committee’s responsibility is to guide decisions and emphasized that the ethics committee are not the ones who are making the decisions for those who seek their advice. Every day, groups gather to discuss the greatest good for the greater number of people; they play the devils’ advocate, so to speak. Ethics committees are no different. While it is sometimes difficult for a group to guide decision making without vocalizing personal opinions or pushing personal agendas, the importance of putting aside self interests for the good of the patient/group should be stressed.
References
Lawrence Memorial Hospital. (2004). Code of Ethics(Rev. ed.) [Administrative Policy]. Lawrence, KS: Author.
Lawrence Memorial Hospital. (2006). Ethics Committee(Rev. ed.) [Administrative Policy]. Lawrence, KS: Author.
Lawrence Memorial Hospital. (2007). Informed Consent Policy (Rev. ed.) [AdministrativePolicy]. Lawrence, KS: Author.