CorrEthics

By Dean P. Rieger, MD, MPH, CCHP

Posted on February 12, 2012 – What follows is a real-life patient care dilemma that illustrates the major ethical principles that have been highlighted in this column. The circumstances were not uncommon in correctional health care, but they played out in a somewhat unusual way.

A patient with Crohn’s disease had been maintained in the community on mesalamine, one of two 5-ASA medications commonly used in inflammatory bowel disease. Both work via the same active molecule; however, the cost of mesalamine is approximately fifteen times that of sulfasalazine. The advantage of mesalamine is a decreased likelihood of stomach upset from the drug as compared to the sulfasalazine preparation. When resources are a concern it is common practice to attempt a trial of sulfasalazine prior to a trial of mesalamine, for reasons that are obvious.

In the community, the patient had no resource concerns and he used mesalamine without an initial trial of sulfasalazine. The patient resisted the facility’s attempts to try sulfasalazine, which included a consultation with the patient’s original gastroenterologist (who was comfortable with the trial). The patient absolutely refused.

The federal courts have reviewed many cases in which inmate patients have demanded treatments other than what is offered to them and, as long as the practitioners are reasonable and appropriate in addressing serious medical conditions that may be present, have confirmed that it is the practitioner and not the patient who can make the treatment selection.

The facility staff held firm, but so did the inmate. Soon he deteriorated, experiencing the usual symptoms associated with Crohn’s, but still he refused sulfasalazine. He was treated with a short course of corticosteroids and repeatedly counseled. The corticosteroids successfully treated his flare, but within a matter of weeks, he was again deteriorating and started on a second course of steroids. This is, of course, an unacceptable way to manage a patient with Crohn’s, and the chronic use of steroids for a patient who could be successfully managed with 5-ASA medication cannot be justified.

Concerns for patient autonomy would lead to provision of the medication the patient demanded. Beneficence would steer towards the best treatment so long as it did not hurt others, and non-maleficence would steer to a course of care that did not cause harm to the patient (or others). But all of this was occurring in a setting where justice concerns, as articulated by the courts, permitted insistence upon a trial of sulfasalazine. And permitting the patient to dictate care choices had the potential to cause harm to others by using scarce resources without clinical need.

The challenge took place in a correctional system where health services are privatized, which allowed opportunity for multiple consultations. These included the attending physician, the regional medical director, the system’s physician consultant, and the system’s director (an experienced nurse practitioner) and as mentioned above the patient’s outside physician. All agreed that this circumstance was harmful to the patient, that the patient did not have the right to choose his treatment, and that input was needed from experienced attorneys.

At different times and in different places autonomy is provided to patients with greater or lesser impact. In this circumstance, the involved decision makers tried to balance concerns for autonomy with concerns for “doing no harm” while maintaining control in a correctional environment. What would you have done?

Dr. Rieger is the Corporate Medical Director for Correct Care Solutions in Nashville, Tennessee. Contact him at drieger@correctcaresolutions.com.