Case Study 1: The Nurse and Cost Containment: Duty to Society Case Study Assignments Ramon Ortega, a 42-year old farm laborer with a history of hypertension, had been experiencing headaches on an almost daily basis for 2 to 3 weeks. Disturbed by the persistent and severe nature of the headaches, he visited the state-supported health clinic serving his rural community. Ms. Tracey Anderson, the family nurse practitioner and sole staff member of the clinic, listened as Mr. Ortega describe his headaches. She then performed an initial examination, which revealed good general health with the exception of an elevated blood pressure of 190/108. Since Mr. Ortega had described some dizziness and visual disturbances during his headaches, Ms. Anderson also completed a neurological assessment. Everything seemed within normal limits except for Mr. Ortega's peripheral vision. Ms. Anderson's assessment demonstrated that he had some difficulty seeing objects in the visual field on his left side. Ms. Anderson realized this disturbance was probably a manifestation of his present headache in combination with his known visual deficit. Since no other abnormalities were identified, the possibility of a more serious problem seemed remote, according to Ms. Anderson's judgment. Yet Mr. Ortega was very distressed by his headaches. He asked the nurse practitioner what he could do to prevent the headaches or, at least, what could be done to lessen the pain he was experiencing. Could she be sure no other problem was causing the headaches? A few months ago, Ms. Anderson would not have hesitated to refer Mr. Ortega to University Medical Center, 100 miles away, for an exam by a physician and a neurologic evaluation of his headaches. She would have done this for no other reason than to relieve the patient of his worry and to confirm the absence of a more serious problem. She believes that, a referral would be of some help. In recent weeks however, the state agency that provides funding to the rural health clinics had urged all health clinic personnel to be careful in referring patients for costly lab or evaluative testing and in incurring the added expense of clinic-sponsored transportation. There are decreased monies to support the personnel and services in rural health clinics because the agency had adopted a strict cost-containment program. In fact, the continued operation of the rural health clinics depended on how well the individual clinics contained costs, even though they provided greatly needed services to populations like the low-income farm community in which Mr. Ortega lives. Ms. Anderson had been cutting the operating costs of her clinic in every way she could, particularly in her judicious referral of patients to the University Medical Center. But she could not overlook the fact that Mr. Ortega was distressed by his headaches, and there was always the possibility, albeit remote, that he was presenting early signs of impending cerebrovascular disease, the effects of which could seriously affect him and his family. She was uncertain about what choice to make. 1. If Mr. Ortega was your patient, which action (s) would you take? In this instance, there is no reason to proceed. That is not Ms. Anderson's issue. She has determined that a neurological evaluation of Mr. Ortega would be beneficial. It would bring some psychological consolation and may disclose therapeutically valuable information. Almost all moral traditions incorporate some notion of moral responsibility to do good for others, or "promote beneficence," as current philosophy would put it. Mrs. Anderson believes that beneficence is at stake. Her perception is right, but in this case, the patient's and others' interests may be at odds. Worse, Ms. Anderson's cost-consciousness may directly help other patients in her rural health clinic location. The money saved by compromising Mr. Ortega's interests will go to other patients whose wellbeing she must also serve. She seems to have two primary possibilities. First, she might follow the CNA Code of Ethics for Nurses' conclusion that "the nurse's main obligation is to the patient's health, well-being, and safety." If the patient's welfare is paramount and she determines that a referral is in his best interest, her moral problem is resolved. Concern for others' wellbeing is ethically subservient to concern for one's own. If that moral priority is adopted, then implementing the province's cost-cutting mandate is ethically inappropriate. Of course, someone in the province needs to care about society. So they may limit Ms. Anderson's referral options. In other situations, she may not be allowed to make a reference even if she believes it is in her patient's best interest. Mrs. Anderson's alternative choice is to give up on the idea that patient care always trumps public good. That would allow her to consider the implications of her decision on the government, taxpayers, and other customers. From this viewpoint, she may endeavor to do the best by considering everyone's wellbeing. She may strive for the greatest benefit for the greatest number. Optionally, Ms. Anderson might weigh some societal advantages but not others while deciding whether or not to prioritize her patient's treatment. The balance of the two interests may depend on whether she made commitments to her patient or to the province that funds her clinic. Maybe it's all about how she sees her duty as a nurse. It may rely on the urgency of her patient's requirements and those who may benefit from the finances. A nurse, the profession, patients, or others in society may see any of these things as ethically significant. In many ethical circumstances in nursing, the first significant moral concern is how patient benefits connect to other advantages. 2. What factors would be important to you in making decisions about Mr. Ortega’s care? Healthcare expenses and budget cuts have prompted health professionals like Tracey Anderson to consider the socioeconomic implications of their actions. Nurses can make certain cost-cutting measures without moral issue. Some operations may be ineffective or even harmful to the patient. If a procedure may harm the patient more than it will assist, it should be avoided. Saving money is a happy by-product. If the surgery offers about equal benefits and harms for the patient, and if the patient has no strong preferences for it, the fact that it would be expensive for the clinic could be a valid reason to avoid it.
