Fiona’s twenty-two-year old daughter was killed in a car wreck. Fiona took custody of her two grandchildren and worked as a housekeeper in a private home while the children were in school. Fiona had no health insurance. She earns too little to buy an individual plan and too much to qualify for Medicaid. When she started bleeding, she just kept buying napkins to absorb the blood.
She continued to work until she collapsed on the job and was taken to an emergency room. Once there she was diagnosed with uterine fibroids, a treatable condition. But in the ER her bleeding stopped. She received a transfusion and was released.
Three months later Fiona was back in the ER, again with uncontrolled bleeding. This time, while she was being stabilized, the bleeding became a mere trickle; again, she was transfused, given the name of an OB/GYN physician to see, and released. Fiona tried as much as possible to do what the ER providers suggested. She did not, however, make an appointment with the physician because she feared medical debt. The bill from her first ER visit, including the ambulance ride, exceeded two months’ salary.
Twice more Fiona visited the ER, but her medical problem was not treated either time, though she was encouraged to get help. On the fifth ER visit, Fiona was admitted to the hospital and even though she was not insured, the hospital consented to allow her to undergo an “elective” hysterectomy.
Fiona has been billed for the surgery, and is attempting to pay. She is depressed, however, because she knows she can never finish paying this bill, given her current employment.
Questions for Discussion
1. Step into Fiona’s shoes. What else would you do besides go to the ER five times?
2. Many physicians and nurses in ERs work three 12-hour shifts a week. It could easily be the case that Fiona was seen by different staff members each time she came. But her medical record has the history of each visit. Role play the procedure that your ER would have used when Fiona comes for her third visit.
3. According to EMTALA regulations, no hospital is required to provide post stabilization procedures. But does a moral obligation increase with each of her visits?
4. Is Fiona’s hysterectomy an elective procedure? Why? Why not? What difference does it make?
5. Are the procedures for debt collection at your hospital regularly reviewed by your ethics committee? Why? Why not?
6. At your hospital, who would advocate for Fiona? Who would help her contest the bill, especially if it represented the full amount that her hospitalization cost the institution?
Sharon Lee, MD, is founder and medical director of Southwest Boulevard Family Health Care Center in Kansas City, Kansas.
Rosemary Flanigan, PhD, is professor emeritus of Rockhurst University and a program associate at the Center for Practical Bioethics.