Mother’s lie raises issues surrounding patient fraud
Few guidelines exist for physicians
The recently reported true story of a 63-year-old woman giving birth with the help of fertility drugs is raising questions about patient truthfulness and the significance of age in determining when motherhood is appropriate.
"If past experiences with these medically produced cases of the oldest mother ever’ are any indication, we will soon witness ethical hand wringing and calls for action," says Alexander M. Capron, LLB, co-director of the Pacific Center for Health Policy and Ethics at the University of Southern California in Los Angeles. "But it would be a mistake to translate our instinctive sense that it’s unnatural’ for women this old to become pregnant into legislative prohibitions," he contends.1
There are larger questions raised by the record-setting event as well, Capron says. A member of the National Bioethics Advisory Commission, based in Washington, DC, Capron suggests that in the future, the commission may want to explore the broad questions raised by the plethora of new reproductive technologies.
Another issue triggered by the birth is that of honesty between doctor and patient. The fertility program at the University of Southern California in Los Angeles, in which the 63-year old woman had enrolled, has an age limit of 55. The woman was aware of the age cutoff and told the doctors she was 53.
Did this patient mislead her doctor in an unethical way? Do patients lie under other more serious medical circumstances as well? Do they lie in ways that may cause ethical or legal dilemmas for your institution, not just the doctor, such as insurance fraud? Do they lie, for instance, to gain entry into clinical trials? "Anecdotally, I have certainly heard [of patients lying] over the years," Capron says.
Like most ethical questions, when examined a few layers beneath the surface, this dilemma regarding the doctor/patient relationship has no clear answer, says Neil J. Farber, MD, an oncologist/hematologist at the Veterans Affairs Medical Center and the Allegheny University of the Health Sciences, both in Philadelphia.
Study examines physicians’ reactions
Farber and five colleagues recently completed a study in which 1,000 physicians from across the country were surveyed about the prevalence of patient dishonesty, specifically about insurance coverage for medical treatment.2
The goal of the study was to determine whether physicians actually reported patients who lied and what circumstances made them more likely to breach confidentiality. In general, Farber found physicians more likely to inform health insurers of fraud when patients had records of previous fraud, substantial wealth, and an acute illness. They were less likely to report terminally ill patients.
In the survey, physicians indicated their moral judgments of patients would influence their decisions to breech confidentiality. "Wealthy patients may be seen as more immoral than poor patients. Similarly, terminally ill patients may generate more sympathy than acutely ill ones who will recover," the authors stated.
Capron recommends that in any situation involving actual fraud, the physician should not become part of the fraud. Nor, he says, should the physician breach confidentiality. "Tell the patient that all information submitted by the physician [to the insurer] will be accurate to the best of the physician’s ability," he recommends. "If the patient is not happy with this, the physician should suggest that the patient find another doctor."
Farber says one of the major difficulties in making decisions about patient fraud and lying is that so few guidelines exist to tell a physician how to react. Laws tend to support confidentiality. If a case of insurance fraud ends in a dispute, the court would rule whether the patient had done something that ends the physician/patient privilege on confidential information, Capron says.
Courts generally allow physicians to breach confidentiality when important social interests are at stake, Farber says. These situations include infectious diseases and certain diseases and situations that, taken together, might cause harm to others. For example, physicians must report cases of epilepsy to state motor vehicle departments. Child abuse, elder abuse, and in some states, domestic abuse, always must be reported to state social service agencies.
References
1. Capron AM. Medicare won’t be swamped with pregnancy claims. LA Times April 25, 1997:9/B.
2. Farber NJ, Berger MS, David EB, et al. Confidentiality and health insurance fraud. Arch Intern Med 1997; 167:501-504.
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