Is It OK to Police My Patient’s Financial Choices?

I’m a family physician. A young woman expecting her second child came to me for obstetric care. She had a black eye — not the first one, she told me. She worked as a topless dancer, but her boyfriend was so controlling and abusive that she did not have money of her own; he didn’t even let her have much gas in her car. We developed a relationship meaningful to us both.

About a year later, she told me that she was getting breast augmentation, at a cost of thousands of dollars, which she intended to pay for in cash from her earnings. Around the same time, I discovered pre- to early cancer in her reproductive tract, and treatment was imperative to prevent progression of the disease, or risk dire consequences. She was insured by Medicaid, which is paid for with tax dollars. I think she probably didn’t report her entire income to the I.R.S. or Medicaid, or she probably would not have been eligible.

I told her I didn’t think I could ethically bill Medicaid for the diagnosis and management of the potential cancer while she was paying cash for breast surgery. (I was also not willing to risk my medical license, though I did not say this to her.) I told her we’d need to look at payment options and discuss them at her next appointment.

She never came back. I still wonder what happened to her and pray she found a new, self-respecting way of life. I wonder if I handled it as well as I could have. — Name Withheld

From the Ethicist:

Your relationship with this young woman was not that of an accountant or a tax auditor but that of a health care provider. True, she chose to disclose something that gave you grounds to believe that she had been misreporting her income. But there are people whose job it is to deal with that issue (although fraudulent claims submitted by providers are a bigger problem for Medicaid than ineligible recipients are). You say you didn’t want to risk your medical license. Has anyone you know lost a medical license because a patient misrepresented her income to the state Medicaid program? Whatever your personal opinions might be about this woman’s livelihood, your job was to keep her healthy, not to keep her honest.

Here’s another question. Would society be better off if doctors were known to refuse to process Medicaid claims when patients gave them reason to suspect that they had underreported their earnings to the government? Under those circumstances, surely, such patients would learn to be more discreet around doctors — which might mean refraining from providing medically relevant information. I understand that you didn’t want to be a party to fraud. It’s still best if doctors aren’t in the business of assessing their patients’ income tier and policing eligibility. Burdening someone with high out-of-pocket expenses can be just as limiting to patient care as overt refusals to provide treatment.

That’s especially true in this case. Because her abusive boyfriend controlled her money, you were leaving it to his discretion whether to pay for her cancer diagnosis and management, and he doesn’t sound like someone who could be trusted to look after her best interests. Given your specific duties of care, your priority wasn’t to look after the government coffers; it was to look after your vulnerable patient.

A Bonus Question

Our family partnership owns a farm field that lies diagonally across a road from an electrical substation. Because of its proximity to a power-distribution source, we receive requests to establish a solar-panel power facility on that land.

My son believes we should contract for such a facility because of the need for renewable energy and the income it would provide for our partnership. My daughter is concerned about the impact it would have on wildlife. My concern is about taking the land out of production and the financial impact it would have on the farmer who rents the land.

My husband is deceased, and I control his voting interest. I believe he would side with our son, because of the income prospects. How can we decide this based on the equally important competing interests? — Name Withheld

From the Ethicist:

Here’s my rough-and-ready take on the considerations you’ve mentioned. As for wildlife protection: You’re not proposing to clear a wilderness; the field in question is being used as cropland. I’ll assume that it’s being conventionally farmed, which normally involves tillage, chemical fertilizers and pesticides — with a net negative impact on the environment. Solar farms can harm some wildlife, too, even as they provide shelter for other wildlife. Would the shift from commercial farming be better or worse for wildlife? Let’s call it a wash.

Nor is it obvious that a potential negative financial impact on the farmer — assuming he isn’t someone you have a close personal relationship with, and assuming he’ll be given proper notice — should outweigh the positive financial impact on the family, and whatever that might enable. (Your daughter, for example, might end up with more money to devote to wildlife conservation.) I don’t see that the need for food is a concern: The United States, with its extensive farm subsidies, is already the top exporter of agricultural commodities in the world. That leaves us with the benefits of increasing the supply of renewable energy — and the particular efficiency with which this energy can be distributed to the substation, given that shorter transmission lines involve less energy loss. In this case, what’s in your family’s interest may also be what’s in our collective interest.

Readers Respond

The previous question was from a reader who was privy to sensitive information about a couple. He wrote: “A woman I know often complains about her ‘manic’ husband. He is a war veteran in his late 50s who owns a very successful business and is the primary breadwinner for their family. (They have no children.) The wife, a woman in her early 60s who works part time and is dependent on his income, recently told me she dissolves melatonin in the water he takes with him to work in order to ‘calm him down.’ She said, ‘I told him it was a nutritional supplement, something to help him because he sometimes doesn’t eat lunch.’ I looked a bit shocked at her confession, and she immediately justified her actions by saying: ‘You don’t have to live with him. He doesn’t take his medications. Now he’s calmer.’ She did not ask his permission to add melatonin to his drinking water. … I am seriously considering revealing this subterfuge to her husband, whom I know. … If my wife did this to me, I’d be apoplectic. I’d appreciate your counsel.”

In his response, the Ethicist noted: “First, any benefits from this ‘treatment’ could well be a second-order placebo effect. As an expert I conferred with confirmed, there’s no serious evidence that melatonin is a useful treatment for mania, and there’s no evidence to support this daytime, waking-hours use of melatonin at all. The main thing that melatonin has been shown to do is help induce sleep. Taking it during the day is an especially bad idea, because it can disrupt your body’s internal clock, and because daytime sleepiness can lead to accidents. In any case, if your friend’s husband is meant to be on other medications, he should consult with a doctor before taking melatonin (or any other drugs) regularly. … Medicating mentally competent people without their fully informed consent is wrong. Giving drugs to a spouse in this way is an abusive betrayal of marital trust.” (Reread the full question and answer here.)

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Yikes! Of course it is highly unethical to give anyone any sort of drug without their knowledge. I agree with the Ethicist here. Having lived for 30 years with a spouse who had bipolar disorder, I would say another approach is to keep having honest, compassionate conversations about how the illness affects the relationship and how to work with therapy and prescribed medications. The subterfuge is a huge violation of trust.— Susan

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I rarely disagree with the Ethicist, but unless you have lived with a manic person (especially one on whom you are dependent), please don’t judge this woman’s actions. Indeed, melatonin is possibly acting as a placebo, but no one can say for certain that it is not acting to calm her spouse. Where mania is involved, there could be all kinds of additional factors unknown to the writer. Bravo to this spouse for finding a safe way to make both of their lives more bearable. The letter writer should let well enough alone. — Ken

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This week’s dilemma reminds me of a recent similar letter to the Ethicist where a seemingly unqualified spouse has diagnosed a major mental or physical disorder — in this case mania, and a couple of weeks ago dementia — entirely based on her own perception and followed by courses of action which may have serious ramifications. Everything the Ethicist says here is absolutely spot-on. However, something that hasn’t been discussed in either case is the possible issue of mental-health issues in the people who are themselves making the claims. To try to secretly medicate one’s apparently highly functioning spouse is not normal behavior and raises serious red flags about the wife’s own mental health. Without being dramatic, if it’s melatonin today it may be something far more dangerous such as Xanax or Ambien tomorrow. If possible, the letter writer needs to have a very tactful conversation with the husband before there’s a disaster. — Sheena

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Although I agree that secretly putting melatonin in her husband’s drink is an abuse of trust, having a husband who refuses to take medication for a mental health condition is also an abuse of trust. Without knowing more about the husband’s condition and prescribed medication and what it’s like to live with him, it’s hard to say more. But as anyone who has ever lived with someone with mental illness — especially someone unwilling to take medication which has proved to be helpful — life can be hell. — Camille

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I agree that it is a gross violation of the husband’s rights to give him drugs without his consent. I especially agree that it is important for the letter writer to inform him since the drug in question should not be given in the daytime. But, assuming the fact of the husband’s diagnosis, I heartily sympathize with his wife. Living with, and being dependent on, a family member with a serious mental illness is a great burden. I believe that the husband’s failure to take his medication is an unethical violation of spousal responsibility on his part. The National Alliance on Mental Illness (NAMI) has support groups for people in her situation; others will understand and have strategies for her. The letter writer should offer this woman more than outrage. — Mildred