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Ethics in everyday practice

The case of Ms. R.

F. J. Gianola, PA

Mr. Gianola is on the faculty of the medex Northwest Physician Assistant Program, School of Medicine and Center for Health Sciences Interprofessional Education and Research, University of Washington, Seattle. He is on the board of trustees of the Physician Assistant Foundation. The author has indicated no relationships to disclose relating to the content of this article.

In our first case, presented in the June 2004 issue of JAAPA, we focused on the medical indications portion of the four-box approach to clinical bioethics. In this our second case, we will examine the contextual features portion. Thanks to my student Irina Peney for presenting this case.

Case

Ms. R. is an 84-year-old woman who is in clinic for a routine follow-up visit for chronic depression, anxiety, and insomnia. While obtaining her medical history, the clinician notes that she has lost weight in the past 2 weeks. There is no history of fever, GI symptoms, night sweats, or fatigue. The review of systems is noncontributory. The results of Pap testing, mammography, colonoscopy, and bone DEXA (dual x-ray absorptiometry) scanning done within the past year are all normal. The medical history includes hemicolectomy for colon cancer (T3 N0 M0), osteoporosis, domestic abuse (both physical and emotional) during two marriages, and depression without suicidal ideation or attempts.

In her present, second marriage, Ms. R. has suffered falls, bites, and multiple soft tissue injuries caused by her husband. She finds it very difficult to leave this situation. Ms. R. describes her husband as loving; but he has problems with anger and impulse control, and he is a binge drinker. He has discontinued his medication for anger and mood control. The incidents of abuse have increased in the past month, and Mr. R. now lives with his son. He controls the family finances. Since his move, he has refused to give Ms. R. any money. She is not eligible for federal or state assistance. Ms. R. has decided to use the money she does have to buy her medication and cut back on buying food. She has three children, a son and two daughters, but her primary support system is her twin sister, with whom she is very close.

Ms. R. now weighs 100 lb, down from a weight 2 weeks ago of 112 lb. She is 63 inches tall, with a body mass index (BMI) of 17.9 kg/m². She has poor dentition and conjunctival pallor. Laboratory tests reveal microcytic anemia, low albumin, and low total cholesterol. Colonoscopy and esophagogastroduodenoscopy do not reveal any abnormalities. Ms. R.'s medications include sertraline, 50 mg/d; olanzapine, 2.5 mg/d; and a daily vitamin with iron.

The ethical question

This case presents many ethical challenges. We will address only one—the one troubling the PA most: "How can I support the patient's choice of medication over food as she falls through the social safety net?"

Discussion

Medical indications (beneficence and nonmaleficence) This section includes the diagnosis, prognosis, and goals of treatment. Ms. R. has lost 12 lb in 2 weeks. She has a BMI of 17.9 kg/m² that is consistent with grade 1 malnutrition,¹ and she has microcytic anemia. Factors contributing to the malnutrition include domestic violence, depression, anxiety, and financial difficulties. Ms. R.'s depression is likely to resolve if she continues treatment with sertraline and remains away from her violent husband. The olanzapine plus appropriate nutrition will provide the proper treatment for her malnutrition. The therapeutic goals in this case are to stop the patient's starvation and restore a normal weight, relieve her anxiety and depression, and resolve the domestic violence.

Patient preference (autonomy) This section addresses the patient's right to choose within the law and ethics. An initial question is whether the patient is competent and mentally capable of making decisions. If so, we must give information about the risks and benefits of treatment, obtain consent, evaluate the patient's ability to comprehend the information, and determine the patient's preference. Ms. R. is competent and able to make independent decisions about her health care. She agrees with the treatment and goals. She vigorously disagrees with the PA, however, about letting her children know about her situation. She insists on confidentiality. She has significant concerns about losing her home and garden. After much discussion with the PA, Ms. R. agrees to have her sister participate in discussions about her health status.

Quality of life (nonmaleficence, beneficence, and autonomy) The third section reviews the issues of restoration, maintenance, or improvement of quality of life. Information needed includes the likelihood of the return to a normal life with or without treatment and what, if any, deficits (physical, mental, or social) Ms. R. may experience if treatment is successful. Does the PA have any preconceived notions that may prejudice the assessment of Ms. R.'s quality of life?

The PA and the medical team believe that the malnutrition must be treated with regular meals that contain sufficient calories. Without this treatment, they believe that Ms. R. will die. The medical team believes that the treatment can be implemented successfully if her children are informed of Ms. R.'s situation. However, the children may decide that selling Ms. R.'s home is necessary to provide her with sufficient funds to buy food.

Ms. R. thinks that she has a very good quality of life. She is independent, living in her own home, and tending her garden. She considers her "poverty" and weight loss to be simply inconveniences. She has expressed concerns about her future quality of life if she is forced to sell her house and lose her independence.

Contextual features (justice) This segment considers the external forces that come into play when evaluating the case. These forces include economic, legal, social, and institutional matters that influence the case. The patient-provider relationship is affected by the society they live in and their duties to the social order.

In Ms. R.'s case, her financial burden is significant. Her nonliquid assets (that is, her house) prevent her from obtaining assistance from social service agencies. Ms. R. wholly owns her home and may need to spend down to receive some assistance. Her husband has control of all liquid assets at this time and is not making them available to Ms. R. Her family is unable to support her financially.

Ms. R.'s situation is shared by a significant percentage of older Americans today. Wellman and colleagues² state that between "8% and 16% of the elder population in the United States experience food insecurity within a six month period" and only about one third of eligible poor elders access the federal programs that provide assistance in buying food. Rank and Hirschl³ point out that 40% of Americans aged 60 to 90 years can expect to be living below the poverty line for a year, and 48% will live at 125% of the poverty level.⁴ The poverty line for a single person is $9,039 a year.⁴ From 1999 to 2003, federal funds of an estimated $26.2 billion have been cut from food and nutrition assistance programs for children and elders.⁵

Recommendations

The medical team offered several suggestions to address Ms. R.'s financial crisis and answer the question, "How can I support her choice of medication over food as she falls through the social safety net?" They worked to get permission from Ms. R. to inform her sister about her condition; to clarify for Ms. R. her options for assistance with food stamps, a food bank, or other food support agencies, possibly with the help of a social worker; and finally to help her identify legal resources for low-income elders.

The next question for the PA is what responsibility the clinician has to address the patient's poverty. According to the "Statement of Values of the Physician Assistant Profession,"

• "Physician assistants hold as their primary responsibility the health, safety, welfare, and dignity of all human beings.

• "Physician assistants uphold the tenets of patient autonomy, beneficence, nonmaleficence, and justice."⁶

We are compelled to address the problem in this case by finding solutions for Ms. R.'s weight loss, which has been caused by her poverty and inability to access resources. There are as many ways to discharge this responsibility as there are clinic systems and support services. However, the issue must not be ignored. Addressing the issue may well mean increasing the members of the care team to include legal and social services, especially for the people in the community who, like this patient, are clearly victims of societal inequities and inefficiencies.

REFERENCES

1. Nelson K, Brown ME, Lurie N. Hunger in an adult patient population. JAMA. 1998;279:1211-1214.

2. Wellman NS, Weddle DO, Kranz S, Brain CT. Elder insecurities: poverty, hunger, and malnutrition. J Am Diet Assoc. 1997;97(10 suppl 2):S120-S122.

3. Rank MR, Hirschl TA. Estimating the proportion of Americans ever experiencing poverty during their elderly years. J Gerontol B Psychol Sci Soc Sci. July 1999; 54:S184-S193.

4. Boushey H, Brocht C, Gundersen B, Bern J. Hardships in America: The Real Story of Working Families. Washington, DC: Economic Policy Institute; 2001.

5. Jones JY, Richardson J. Federal food programs: legislation in the 104th Congress: Congressional Research Service report for Congress. Washington, DC: Congressional Research Service; October 29, 1996. Document 96-861 ENR.

6. Statement of values of the physician assistant profession. Guidelines for Ethical Conduct for the Physician Assistant Profession. Available at: http://www.aapa.org/policy/ethical-conduct.html#Heading65. Accessed July 11, 2004.