Markkula Center of Applied Ethics

A Hospital's Ethical Obligation to the Uninsured

Response to the Case of Madisyn Whitfield
By Nick Welter

While at face value, it may seem that the hospital has a clear-cut ethical responsibility to offer Maddy free, or reduced-cost care for her medically necessary stay, ethical issues are hardly ever that black and white.

Maddy's situation is certainly a dire one-her condition is likely to deteriorate further if she doesn't find a way to pay for the surgery and get back on a proper diet and medication regimen that will keep the Crohn's flare-ups in check. Her medical condition has started to interfere not only with her education and work, but also with her quality of life. Ignoring the condition or "toughing it out" is not a viable option, but based on her family's financial situation, neither is paying for the operation. This is truly a situation where outside help is necessary. The hospital, as an organization devoted to the health of the local community, has an ethical obligation to help Maddy despite her financial circumstances.

That said, there is also the health of the greater community to consider. Hospitals, contrary to how they are commonly perceived, are in essence businesses. While making a profit is not the true concern here, a hospital cannot simply provide free care to everyone in the community who might need it. If a hospital loses enough money through providing care for those who cannot afford it, it will eventually be forced to close. Allowing a hospital to operate in a way that jeopardizes its continuing existence not only threatens to put hundreds out of employment, it threatens the health of everyone in the community being served. For these reasons it is impractical and even shortsighted to think that the hospital is acting unethically when it refuses treatment to those who can't pay.

Because it is unethical to refuse treatment to everyone who can't afford it, and equally unreasonable to provide free care to everyone who might need it, a hospital must make an extremely difficult decision and evaluate patients on a case-by-case basis. In Maddy's case, her circumstances seem completely out of her control and a full recovery seems likely if she can receive proper care. While the hospital shouldn't necessarily be expected to treat Maddy free of charge, this particular case is one in which a small financial loss to the hospital would bring about a great increase in Maddy's quality of life.

Although not a possibility this far along in the case, providing reduced cost preventative care would have been a much better option for all parties involved. Maddy's deterioration could have been easily avoided had she been able to afford her medications in the first place. The hospital should seriously consider a program to subsidize preventative medications for the community; the cost involved in admitting a patient, performing surgery, and providing intensive care support far outweighs the relatively minute cost that would have been incurred in simply subsidizing Maddy's medications. While they have traditionally not been well- supported in the United States, preventative care programs provide hospitals a means of reconciling the ethical obligation to treat financially disadvantaged patients and the obligation to remain open to serve the greater community.

Nick Welter was a 2008-09 Health Care Ethics Intern at the Markkula Center for Applied Ethics.

July 2009

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