Question on medical ethics in the private sector

[Prometheus]

It is reasonably common for health professionals to make medical decisions on behalf of a patient who is deemed  incapable of making such decisions due to deteriorating mental health. Next of kin are usually consulted, but for this hypothetical scenario assume there is no next of kin for whatever reason.

In this scenario it is deemed medically necessary to perform surgery, but it is a private setting so the patient will have to pay. Health insurance won't cover it for whatever reason.

Can the health professionals force the patient to pay? Do the courts need to get involved in this decision since money is involved?

I'm interested in how this would work in the US setting - or any other predominantly private healthcare setting.

[John Cuthber]

Interesting question.

On a related note, what would happen if the patient was perfectly able to make their own decisions, but unable to pay?

[zapatos]

Since the person is mentally incapable of making decisions, I imagine the courts will appoint a guardian who is responsible for making medical and financial decisions on their behalf.

Assuming the guardian is appointed after the surgery was done, and the surgery was necessary, and the patient had the funds, I believe the guardian will be compelled to pay.

[John Cuthber]

I don't see why people should be punished for being guardian to those in need.

[Strange]

3 hours ago, John Cuthber said:

I don't see why people should be punished for being guardian to those in need.

I think he means that the guardian would be compelled to ay from the patient's funds.

On 23/09/2018 at 9:09 AM, Prometheus said:

Can the health professionals force the patient to pay? Do the courts need to get involved in this decision since money is involved?

As this is a private setting, it also depends on the contract between the patient and the healthcare provider

[Prometheus]

6 minutes ago, Strange said:

As this is a private setting, it also depends on the contract between the patient and the healthcare provider

Let's say that the patient and healthcare provider had no existing contract. The healthcare team earnestly assess surgery to be in the patient's best medical interest and they (somehow) know the patient can afford it.

 

6 hours ago, zapatos said:

Assuming the guardian is appointed after the surgery was done, and the surgery was necessary, and the patient had the funds, I believe the guardian will be compelled to pay.

And a guardian is appointed by a court? We're basically talking about giving someone power of attorney over the patient.

[Strange]

15 minutes ago, Prometheus said:

Let's say that the patient and healthcare provider had no existing contract. The healthcare team earnestly assess surgery to be in the patient's best medical interest and they (somehow) know the patient can afford it.

I would assume that if there is no contract but the healthcare team decided to operate anyway, it would be considered a pro bono act. You can't impose a contract on the patient afterwards. No contract, no need to pay.

[zapatos]

3 hours ago, Prometheus said:

 

And a guardian is appointed by a court? We're basically talking about giving someone power of attorney over the patient.

Correct.

[John Cuthber]

If the patient can afford it, then it's reasonable for the hospital to treat them, then send them the bill, on the basis that the patient is better off  with their health, but less money.

However, there's no contract, so I'm not sure it could  be enforced. The patient could claim that they would have preferred to remain untreated- even if they consequently died. So, on the whole, I think Strange is right.

 

The idea of appointing a guardian via the court is  interesting but unrealistic. The timescale would usually prevent that option.

 

[zapatos]

2 minutes ago, John Cuthber said:

 

The idea of appointing a guardian via the court is  interesting but unrealistic. The timescale would usually prevent that option.

 

Appointing a guardian prior to the surgery would be unrealistic, but it seems inevitable that a guardian would be appointed sometime afterward. Someone has to make decisions for the person who is incapable of doing so for themselves.

Prior to the surgery I believe hospitals use an ethicist to make such decisions. 

[John Cuthber]

1 minute ago, zapatos said:

Appointing a guardian prior to the surgery would be unrealistic, but it seems inevitable that a guardian would be appointed sometime afterward. Someone has to make decisions for the person who is incapable of doing so for themselves.

Prior to the surgery I believe hospitals use an ethicist to make such decisions. 

I hope the ethicist is a quick thinker.

My understanding is that the process is more like this

Does he gave a gold card?

Yes-

OK we operate

 

 

No-

Stabilise him + send him to the charity hospital down the road.

[zapatos]

The ethicist would also be involved in whether or not the patient is sent to another hospital. There are times when it is illegal to transport them, and all hospitals do work they are not compensated for.

[CharonY]

4 hours ago, zapatos said:

Prior to the surgery I believe hospitals use an ethicist to make such decisions. 

It would depend on the circumstances, I believe. In emergency situations and when the patient is unable to give consent, the usual requirement for informed consent to procedures can be waived. There have been court cases and if it can be demonstrated that the procedure was indeed a medical necessity and there was no way to obtain consent without harming the patient (e.g. patient is unconsciousness and there is a time limit), the physicians can go ahead and charge accordingly. 

More interesting are cases were patients could be deemed medically incompetent, and this cannot provide an informed decision. Individually these could be contested. E.g. a very drunk person could need an emergency procedure, declines it, but still gets it to save their life. After sobering up and suing the hospital the courts held that heavy intoxication could be considered a case of medical incompetence. The patient had to pay.

In non-emergency cases they would not be able to perform the procedure without the informed of the patient or legal guardian, even if it was in their best interest. 

[TK421]

In emergency situations, implied consent is the current default standard.  Part of the legal context for cases where consent can't be established is to ask whether or not the physician(s) acted upon good faith (i.e. had good intentions when they made their decision).