More than 65 million Americans are currently enrolled in managed care plans, which have been promoted as effective ways to deliver quality health care while containing costs. But these plans raise increasingly complicated ethical issues. The following case study, a fictionalized account by Center Director Thomas Shanks, S.J., illustrates some of those questions.
Alan and Monica Sinclair have been your friends for many years. Though they live in another state, you are able to get together with them every now and then, and a Sunday night doesn't seem complete without your weekly phone conversation.
These phone calls became even more important when Alan contracted cancer at the age of 40. You've followed his illness carefully ever since he began treatment for non-Hodgkins lymphoma at University Hospital. Alan and Monica found University more than deserving of its reputation as a center of excellence for cancer care. When his early treatment was successful, Alan could only be grateful for the expertise of his doctor and the entire medical staff.
Monica also found the hospital's location an additional, but real, benefit. Close to her home and work, the hospital was convenient for her frequent after-work visits; and their son, Alan Jr., a lawyer, was even able to squeeze in some time with his dad. Their friends, too, would often stop by to boost Alan Sr.'s morale.
Proximity became even more important when the hospital began the monthslong process of harvesting stem cells from Alan's blood, which will be returned to him after his chemotherapy treatments. Alan and Monica learned that these stem cells, which are important to healthy blood, are wiped out by very potent chemotherapy drugs, so it's important to harvest cells early in the treatment. In this Sunday's phone call, Monica, still trying to be brave and matter-of-fact, tells you Alan needs a bone-marrow transplant. You reassure her that she just needs to trust the doctors at University, as she has in the past, and everything will turn out fine. You're sure of it.
"But," she tells you, " Alan's HMO wants to send him to a different hospital -- Fair Oaks -- a couple of hours away. I mean, Fair Oaks is a very good hospital, and they tell me it has a renowned oncology center, but so does University. I don't understand how the HMO can pull Alan away from his home, especially now when he's so sick. I'll probably have to quit my job to be with him, and our other friends and family will never get there. And all those stem cells they've harvested - they'll probably have to start all over again at the new hospital!"
When you ask why the HMO is doing this, she tells you the company saves money at Fair Oaks. The transplant costs from $100,000 to $150,000, and the HMO gets a discount because it has a contract with Fair Oaks. Some other companies have a contact with University, but not Alan's.
"We didn't know this would happen to us," she says. "We knew we might have fewer choices about doctors and hospitals, but who reads all the fine print in those contracts?"
She tells you that Alan Jr. is very upest. As a lawyer, he's been pushing the HMO, but they insist that they are upholding their end of the bargain - providing care at a good hospital and, at the same time, making sure the transplant is done in the most cost-effective way.
"Alan Jr.," she tells you, "got pretty upset when the HMO said they weren't concerned that we would be inconvenienced. They say they are passing all the savings on to their customers, but I don't believe it. This is a for-profit company. I just don't trust them."
How would you sort through the ethics of this situation?
This case was written by Thomas Shanks, S.J., Executive Director of the Markkula Center for Applied Ethics.
Spring 1996