Volume 10, Number 1, August 1999

Case: Beyond Standard Medical Treatment

A patient arrived in the emergency department of a city hospital in an anemic condition. He had been transferred from a smaller rural centre where he had been suffering from a bleeding ulcer for a number of weeks and where efforts to mitigate this problem had not succeeded. The ER physician wanted to give the patient a blood transfusion to build up his red blood cells and counter the anemia. The patient refused the treatment, saying that he was a Jehovah's Witness and that his religious beliefs would not allow him to accept a blood transfusion.

The patient had family within the city. His sister was currently unemployed, having just recently been laid off from a secretarial job. His parents also lived in the city, but they too had little or no income, and in addition, a fair degree of ill health. The patient's sister was living with them and helping to support them.

Upon consultation with the family and learning of their absolute refusal to accept a blood transfusion, the ER physician was left with few alternatives. After some consultation with other physicians and the pharmacy department, he found that there was a drug used with HIV and renal dialysis patients that stimulated red blood cell production and that might be helpful for this patient. But the drug was expensive, and it was not carried in the hospital's formulary. The nearest source for the drug was from another city, and there would be significant costs in having the drug shipped to the hospital in a timely manner.

In addition to the logistics and cost issues, there was also the issue of whether this treatment was covered under the Canada Health Act. Hospitals generally cover the cost of treatments that are considered standard or basic, but they may charge for treatments that are considered above and beyond basic care. For example, if a patient with a broken leg wishes to have a fibreglass cast rather than a plaster cast, a hospital may charge for the difference between the plaster and fibreglass cast. This is because the fibreglass cast is considered as something beyond basic care, whereas the plaster cast is standard.

It was decided to discuss the issue with the patient. A proposal was made to the patient and his family to use the drug, but that a charge of between $600 and $700 would be billed to the patient to cover the costs involved. The justification for this was that it was beyond the standard treatment, which would have been a blood transfusion. The family was not happy about this solution but eventually agreed to accept the charge.

The drug arrived, it was administered to the patient, and he began to recover. However, when the bill was mailed to him, his sister came into the hospital and informed the finance department that she would not pay the bill and that the family had felt coerced at the time that they had agreed to pay for the costs. In addition, they also felt that this kind of expense should be covered by the Canada Health Act, and that just because they wanted an alternative form of treatment, that should not be reason to have this use of the drug considered as something outside the scope of services offered under the legislation. (The drug is covered under the Canada Health Act when used with renal dialysis or HIV patients).

The problem was passed on to a hospital administrator. Rather than dealing with the ethical issues involved, the administrator attempted to find a solution which would relieve the family of the cost burden and not compromise the earlier decisions to get the drug and to charge the patient. The hospital foundation was approached to see if they had money under patient comfort funds and whether that money could be used in this circumstance. It turned out that there were funds available that had recently been donated by a service club that had folded its business and had given the foundation money that could be used for any purpose deemed acceptable by the hospital. But when the administrator went back to the finance department to inform them that the foundation would pay the bill, he discovered that the family had returned and had paid the bill in full. There were rumors that the elders of their church had raised the money within the congregation.

Despite the bill being paid, the administrator felt unhappy with the way events had unfolded. Even though the matter was settled, he took this issue to the hospital ethics committee to have it discussed so that if a similar situation were to arise in the future there would be ethical guidelines in place. The ethics committee, however, agreed with the original decision to charge the patient. Their argument was that society as a whole shouldn't have to pay for the preferences of a minority group that would not accept standard clinical practice because of religious beliefs. Individual preferences might warrant a fibreglass cast, the committee reasoned, but that did not justify the rest of the community paying for such a cast when a plaster cast worked much more cheaply and just as well for the setting of bones. The case was the same, the committee felt, for the blood additive and blood transfusions.