Discussion: This is a difficult—though perhaps not uncommon—problem, one without an entirely satisfactory solution from the physician’s perspective. How does one approach this situation?
The first step is to examine the patient’s medical condition in the context of such factors as the patient’s decision-making capacity, her preferences, and the role of other interests. In this case, these considerations seem relatively straightforward: a woman with longstanding rheumatoid arthritis is currently unable to afford office visits or cover the costs of standard laboratory monitoring due to the loss of her medical insurance. She has been able to afford her medication, which continues to control her disease without apparent toxicity.
The next step, which may be the most challenging, is framing the ethical problem. In this case, the dilemma speaks to your sense of medical professionalism. Should you continue to order a potentially toxic (though effective) medication in a patient who has not had a timely evaluation nor undergone the appropriate laboratory surveillance for relevant toxicities? If so, for how long? Yet, if you refuse, what will happen to the patient? Could such a decision be considered patient abandonment? Finally, put yourself in her shoes, with a chronic disease (that may in itself limit her insurance options), tolerating methotrexate with good effect. If she understands and is willing to take the risks of unmonitored therapy, isn’t she (and society, which may ultimately pay for her disability if she goes untreated) better off with her disease well controlled?
A third step in the process is to consider the role of other interests, in this case medical insurance. Indeed, it is the patient’s loss of medical insurance that sets the stage for the ethical dilemma. It is a circumstance over which you have no control, and for which you are not responsible. Medical insurance is a voluntary contractual agreement between two parties, usually mediated through the patient’s employer. While you could agree to see her without charging for the visit, the same may not be true of the payment for laboratory studies. You have already attempted to secure support for the patient through the social worker, although it is not clear that all available options for the provision of her care have been explored. For instance, could the local chapter of the Arthritis Foundation (or another charitable organization) be approached to provide financial assistance? Would the drug company provide the drug at no cost to the patient? Alternative medical care and insurance arrangements, such as an application for Medicaid, might also resolve this patient’s dilemma. Finally, there is the issue of personal responsibility. One needs to be careful not to “blame the patient,” but are you confident that the patient has been willing to make sacrifices in other life domains in order to find money to purchase the required medical care?
