Monday, September 04, 2006

Can Individuals Be Compelled To Take Preventive Medical Treatment?

My wife posed an interesting medical conundrum to me this evening: what is the appropriate response to a patient who is unwilling to take care of their chronic condition? It may not be immediately apparent what I mean by this, so let me elaborate. My wife, in her position as an ED physician, regularly treats patients with chronic conditions. Most of these patients arrive in the ER through no fault of their own, and do not make subsequent return visits. However, there is a small (but meaningful, in terms of time and resources to treat) subset of these individuals who return to the ER time and again because, it seems, they can't be bothered to undertake the appropriate preventive treatment. For example, my wife regularly sees several individuals who have diabetes-induced kidney failure but don't get dialysis when they are supposed to, requiring another trip to the ED. So that is the situation, what is the appropriate response? It seems that there are three choices in terms of response:
  • Status quo
  • Deny continuing medical treatment
  • Compelled treatment
I'll now go over each of these in more detail. Status Quo In this case we continue to treat the patient when they arrive in the ED subsequent to failing their regimen of preventive care. The main reason that this approach is suboptimal is that it requires the unnecessary expenditure of medical resources. It is a lot more efficient, resource-wise, to provide preventive care than to provide emergency care. If we accept that healthcare is a limited resource then there seems to be a burden (be it moral or economic) to ensure that it is used efficiently, in which case the status quo needs to be changed. To compound the matter further many of the individuals who require such care are medically indigent, being on one form or another of government insurance (usually Medicaid). So not only is there the problem of the inefficient use of medical resources, but there's also the issue that other people are footing the bill for their neglect. So how do we proceed from here? Deny Continuing Treatment If we decide that the status quo needs to change, one approach is to deny continuing medical treatment to these individuals. This would resolve the issue, but its not clear whether such an action is morally defensible. To ascertain if it is we need to answer two questions:
  1. Is there a moral obligation to provide treatment?
  2. If there is an obligation, what are its boundaries?
The consensus regarding Question 1 seems to be "yes"; I'll assume this to be so since arguments to the contrary exceed the scope of this particular post. But the boundaries question is fair game, so let's take a look at that. Why do we provide treatment? There are many ways to phrase the answer, but they all boil down to "its the humane thing to do". If a person abuses the system, or fails to be an active participant in their treatment, does this lessen our obligation? I would think not, since it doesn't challenge the underlying rational for treatment in any way. "But wait", you say, "can't a person decline treatment?". Most certainly, but the person doing the declining needs to be making such a decision in a rational manner. In the cases which I've discussed above there doesn't seem to be a well thought out decision to decline treatment for their illness; the fact that the patient continues to return to the ED indicates that treatment is desired. So it would seem that we can't deny treatment to these problem individuals either. Which brings us to the third alternative. Compelled Treatment If the status quo is unsatisfactory, and we decide that we cannot deny treatment, what options remain to us? The patient must be wheedled, cajoled, enticed, and ultimately compelled to engage in an appropriate regimen of care. This seems like a blow to patient autonomy, but consider the following question: Can a patient who prefers multiple trips to the ER over preventive care be said to be behaving rationally? I would argue that they are not; what end is served by such behavior? If they are not behaving rationally, not capable of making reasoned judgments about their medical care, then isn't there ample precedent for overriding their judgement and compelling care? But there's a complication with such an approach when you apply it to persons with chronic conditions. In that case you're not talking about compelling them to accept medical treatment for the duration of their stay in a hospital setting. Rather, you have to make sure that they are getting appropriate treatment for the rest of their natural lives. How does one do that, other than forcibly committing people to some sort of government-run treatment facility? That's a sticky question, yes? Anyone have any ideas?


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