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Potential Ethical Dilemma For Aprn Case Study

April 17, 2007

Ethics concerns grow for NPs and PAs

As out-of-pocket health-care expenses increase, patients are pressuring clinicians to bend the rules, according to an eye-opening new survey.

If you frequently find your clinical judgment thwarted by an insurance company’s unwillingness to pay, you’re not alone. Almost three out of four nurse practitioners and physician assistants polled in a recent survey reported third-party decisions within the past two years that “interfered with their ability to provide” necessary treatment. And more than half of that group (55.3%) said they ran up against such interference daily to weekly.

The goal of managed care is to keep down costs, and the goal of primary care is to maximize a patient’s well-being. When those goals clash, clinicians can find themselves grappling with ethical conflicts. A research team from NIH and several universities in Maryland and Pennsylvania recently explored those conflicts in detail. The results were published in Nursing Research (2006;55:391-401).

NPs and PAs “often feel caught between playing by the rules of the health plan or the system in which they work and advocating for their patients’ best interests,” the researchers stated. “The ethical issues cannot be avoided completely,” said lead author Connie M. Ulrich, PhD, RN, of the University of Pennsylvania School of Nursing in Philadelphia. “There are inherent ethical problems within the health-care system, such as concerns related to quality, cost, and beneficent care for patients. This creates challenges for providers in knowing how to best allocate care given the cost constraints.”

Ulrich’s team sent a questionnaire to a stratified random sample of 3,900 NPs and PAs nationwide. The 1,536 who responded had been in practice for an average of 10.5 years, and 19% had more than 20 years of experience. Most (73.5%) were generalists in family practice, internal medicine, pediatrics, or obstetrics/gynecology.

Annual health-care spending is expected to reach $3.3 trillion by 2013. As consumers pay more in health-care premiums and out-of-pocket expenses, they may be more likely to pressure providers to mislead third-party payers to gain coverage. Ulrich’s study cites a 2004 University of Pennsylvania survey of physicians and patients, which found that 26% of the general public supported deceiving insurers.

That pressure to deceive is being applied to NPs and PAs, especially as their role in primary care continues to expand.

Some willing to game the system Almost half the respondents in the new survey (47%) said at least one patient had asked them to mislead his insurance company to obtain coverage. About two out of three of the clinicians (63%) said they would “probably or definitely” refuse the request, but about one in four (27%) found it ethical to “game the system” (Figure 1). On the other hand, 73% said they would help patients fight for denied services, either through an appeals process or by helping patients appeal to insurers.

Among the survey’s other major findings:

• 58.2% of NPs and PAs believe managed-care values and clinical-practice values are at odds with each other.
• 52.7% said that it is sometimes necessary to bend the rules.
• 31% agreed it is sometimes necessary to report only partial truths to insurance companies.
• 39.9% agreed it’s sometimes necessary to exaggerate an illness.

Most respondents were concerned about the implications of choosing between clinical care and costs. For example, more than four out of five (85.5%) worried about “patient interests being overridden by business decisions,” and three out of four (75.4%) were troubled by the prospect of clinicians “evolving into an agent for the health plan instead of the patient” (Figure 2).

Click to Enlarge

The level of actual conflict reported over ethical issues was related to the importance clinicians attached to their role as patient advocates, the strength of their belief in playing within the system, and how often they encountered resistance from insurers. Adversarial patient relationships, patient demands for unnecessary treatment, and practicing in a for-profit setting were also associated with more intense feelings of conflict. Similarly, lower levels of conflict were reported among clinicians in group-model HMOs or large physician-group practices (>50 physicians), those who had the most autonomy, and those who had confidence in their decision-making.

“Clinicians need support in their clinical-practice organizations to bring forth ethical issues they encounter,” said Ulrich. “They need to work collaboratively with their colleagues and establish a safe and open dialogue surrounding ethical issues in practice.”

More ethics training needed

How should a clinician approach an ethical conflict? Although 44% of the sample said that adequate attention had been paid to ethical issues during their training, more than one in four reported a sense of isolation, and more than two out of three (68%) said that more ethics training is necessary.

“Both medical and nursing schools need to do better at educating clinicians regarding ethical issues in practice and the ethical frameworks they can use to identify the facts of each case, the relevant ethical issues, professional and legal positions on the issues, and methods for resolution,” Ulrich said.

All clinicians, especially those in primary care, can expect to face continuing ethical questions throughout their career. Other factors adding to the pressure, according to the study, include an aging population with chronic diseases, a growing number of uninsured patients, and disagreements about what constitutes medical necessity.

The researchers call for “greater inquiry to determine whether practitioners are responsible ultimately to the patient, the public, the health plan, or society.”

But the existence of a conflict of interest between providers and third-party payers does not eliminate an ethical resolution. “There’s a fine line, when rationing services due to cost constraints, between providing cost-effective care and bad care,” said Sherril Sego, MSN, FNP, a primary-care nurse practitioner at the Department of Veterans Affairs Medical Center in Kansas City, Mo., and a contributing editor to The Clinical Advisor. “Many acceptable options for drugs and services are less expensive, and it is the job of all providers to monitor these cost-saving efforts to assure we are maintaining quality in the pursuit of economy.”

Ms. Dembrow is a senior editor for The Clinical Advisor.

Posted on 1/02/13

by George Theodore, PhD

QP, a 47-year-old Scandinavian woman, visits her primary care physician (PCP) complaining of abdominal pain. She recounts that she has not been sleeping comfortably during the past 6 months, waking an average of 5 times nightly. Inadequate sleep is causing her to feel fatigued and irritated during the day, impairing her ability to work effectively in her office job. QP explains that she considers her pain to be significant, or else she would not have made the appointment. In her Scandinavian culture, she says, people are encouraged to tolerate pain. Because QP has been experiencing pain for 6 months, her PCP suspects a chronic pain condition and orders a battery of diagnostic tests. After a few days, QP returns to find out that the tests did not reveal any plausible physical causes for the pain. The PCP believes that there may be a psychological component creating or adding to her feeling of pain. He refers QP to a psychologist, whom he describes as a frequent collaborator. After eliminating malingering and factitious disorder, conditions in which a patient falsifies symptoms of illness, the psychologist does not find any psychological basis for the pain. During the office visit, QP tells the psychologist that her teenage son sometimes physically abuses her when he acts out in retaliation to punishment.

The psychologist mentions the abuse in his report to the PCP, noting that QP dismisses the problem and claims that her son is just a “kid being a kid.” During her next visit with the PCP, he asks her about the situation with her son. The PCP undertreats QP with a low dose of pain medication because he is concerned about losing his Drug Enforcement Administration license. In his notes, the PCP refers to the "questionable stability" of the patient.

In response to the PCP's questioning about the physical abuse at the hands of her son, QP feels that her trust has been violated by the 2 health care practitioners. She claims that she spoke with the psychologist about her son in confidence and that the PCP's only role was to assess and treat her pain. She believes that the PCP should not have involved himself in her family's private affairs. From the PCP's perspective, this case raises several questions that bear on ethical principles and practices:

  • Did the PCP have the patient's permission to speak with the psychologist about the domestic abuse? If not, should he have requested and received prior specific consent?
  • Did the patient give the PCP and the psychologist permission to discuss these matters from an informed perspective?

Key Codes of Ethics in Health Care

Professional organizations including the American Medical Association (AMA) have established and promoted codes of ethics for health care practice.1 A foundational ethical principle is to conduct all professional interactions with honesty. Furthermore, respecting the rights of patients and other health care professionals includes providing appropriate informed consent and safeguarding patient privacy and confidence.1 The American Psychological Association (APA) has established a code of ethics that parallels that of the AMA in many regards, aligning with the ethical principles of honesty and respect.2 In this case, QP felt that the PCP did not have the right to know her family's private information and that her privacy was not upheld. When health care professionals do not provide appropriate informed consent regarding information to be shared in referrals and consultations, they violate patients' or clients' rights to privacy. Such instances are contrary to the AMA and APA codes of ethics and to the principle of honesty in professional conduct among physicians and psychologists.

In this case, the regular frequency of referrals from the PCP to the psychologist raises the issue of properly and promptly disclosing potential conflicts of interest to the patient. QP may have thought twice about seeing the psychologist had she known about this regularity of referrals. In recent years, professional and government entities have established strict requirements for disclosing conflicts of interest among physicians who receive payments or gifts from corporate sponsors.3,4 Although these requirements are commonly acknowledged as important, a survey of physicians indicated that their self-reported rate of disclosure ranged from only 50% to 79% depending on the type of payments received.4 Hence, accurate and full disclosure are lacking even in a type of interest relationship in which a considerable amount of effort has been made to disseminate and implement ethical codes. Disclosure subsequent to medical care contributes to feelings of uncertainty in the patient or client and may diminish the essential trusting relationship with the health care professional. Physicians should give considerable attention to the accurate disclosure of any conflicts of interest involving colleagues or collaborators, even though these relationships may not entail receipt of direct payments.

Another key aspect of this case involves the ethical principle of avoiding practice outside one's areas of expertise.1,5 Although QP felt that her confidentiality was not upheld, the PCP did attempt to effectively limit practice within his area of expertise by referring her to the psychologist. In adhering to an indispensable ethical code, it is especially important for physicians to accurately self-assess their expertise in serving each patient's needs; inaccurate self-assessment may lead to diagnostic and treatment errors.6 Based on education and training, the practitioner should regularly reflect on his or her own strengths, processes, and biases, consulting with qualified colleagues in order to practice within identified limits of expertise.5,7

The Process of Ethical Decision Making

Physicians must realize the potentially widespread influence of their treatment decisions, given the ethical responsibilities that they have to themselves, their patients and peers, and society. Although the application of ethical standards and principles to patient care can be complicated by real-life considerations, physicians will benefit from following a valid, consensus process of ethical decision-making.8 In the recently published American College of Physicians Ethics Manual (6th edition), the authors present an 8-step method for guiding ethical decision-making in medicine:9

1.Define ethics dilemmas in terms of “ought” or “should” questions

2.List vital facts as well as uncertainties regarding the ethical question at hand

3.Identify the patient or a proxy (eg, a parent, if the patient is a child) as the decision maker

4.Give the decision maker understandable, relevant, and desired information

5.Inquire about the patient's values that are relevant to the ethical question

6.Identify values that are relevant to medical professional organizations and practice

7.Propose and critically assess solutions involving treatment options and appropriate health care providers

8.Identify and resolve or eliminate factors that might interfere with identified solutions, including reimbursement issues and misconceptions that patients may hold about treatment

Through regular self-assessment and by following a valid process, physicians may consistently and accurately evaluate dilemmas in medical ethics and make ethically sound decisions that lead to optimal outcomes for their patients.


1.American Medical Association (AMA). AMA's code of medical ethics. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics.page. Accessed 12/15/2012.

2.American Psychological Association (APA). Ethical principles of psychologists and code of conduct. http://www.apa.org/ethics/code/index.aspx. Accessed 12/15/2012.

3.Steinbrook R. Controlling conflict of interest — Proposals from the Institute of Medicine. N Engl J Med. 2009;360:2160-2163.

4.Okike K, Kocher MS, Wei EX, et al. Accuracy of conflict-of-interest disclosures reported by physicians. N Engl J Med. 2009;361:1466-1474.

5.Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicineAm J Med. 2008;121(Suppl):2-33.

6.Norman GR, Eva KW. Diagnostic error and clinical reasoning. Med Educ. 2010;44:94-100.

7.Singh H, Naik AD, Rao R, et al. Reducing diagnostic errors through effective communication: harnessing the power of information technology. J GenIntern Med. 2008;23:489-494.

8.Pope KS, Vasquez MJ. Ethics in Psychotherapy and Counseling: A Practical Guide. Hoboken, NJ: John Wiley & Sons; 2011.

9.Snyder L; American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med. 2012;156(1 Pt 2):73-104.

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