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Case Analysis "uninsured on Life-Support"

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Elizabeth Castro-Wilson


Case Study #2

I. Statement of the problems:

        The patient, Malala, is a 20 year old uninsured female who has suffered severe head trauma as a result of an ATV accident. She is currently hospitalized and on life-support. Several neurologists have evaluated her case and all agree that her recovery is highly unlikely or impossible. Her family members have begged for the hospital to continue her life-support because they believe that Malala has been responsive on a few occasions, but those “responses” were unverifiable.

        Malala has been on life-support for 76 days, which costs approximately $14,000 daily. The cost of her emergency treatment prior to being on life-support totaled around $227,000. Although the hospital does receive funding from federal and private sources for charity, those funds have been reserved or already used for expenses and programs. Malala’s family is also unable to cover these expenses.

        The accident, for which Malala was determined to be “at-fault”, happened not long after the Affordable Care Act was initiated. No one has been able to find out if Malala had applied for insurance. According to a family member, it is unlikely that she ever applied for insurance because she had expressed that she did not feel she could afford it anyway. Malala was working two jobs but neither of them offered any insurance benefits.

II. Resolutions to the problems:

The physicians, hospital administration and Malala’s family members all face some extremely difficult decisions in this case. I don’t believe there are any possible “win-win” scenarios here. So, I will be analyzing this case using a utilitarian approach by first identifying the available courses of action, considering what persons and/or organizations will be affected by those actions, and then recommending the action that will produce the greatest advantage and least amount of harm for all.

There is an important lesson to be learned here—if a person does not have or can’t obtain health insurance, for whatever reason, then they should not be engaging in extreme sports. Furthermore, people should not engage in extreme sports at all without understanding the risks and potential consequences involved and how to prevent them (for example, wear a helmet to prevent brain trauma). I understand most 20 year olds aren’t thinking ahead like that, but this is the general “moral of the story” that comes to mind while analyzing this case. Malala’s injuries and the current moral dilemma are all consequences of carelessness and poor judgment.

A question that came up in my mind when analyzing this case was the possibility of Malala’s state offering emergency Medicaid benefits. Here in Arizona, I believe that the hospital will submit an application for any uninsured patients in the emergency room. Sometimes Medicaid will approve assistance for just the one emergency encounter, and other times they will approve and continue coverage forward for the patient. It was mentioned that there was a health insurance exchange set up in her state following the initiation of the Affordable Care Act, but there was no evidence that Malala ever applied for benefits through her exchange. Surely there would have been a plan option available to her at little to no cost per month. Perhaps she just wasn’t aware of or didn’t understand the options available to her, since it sounds like she just assumed that she would not be able to afford a plan.  

One hospital representative suggested that Malala be transferred to another facility or life-support be discontinued in 7-10 days. The representative offered to cover all the transfer expenses (approximately $25,000). Malala’s care at the hospital thus far has totaled approximately $1.3 million. Since the family cannot afford to pay for her care and the hospital currently has a very limited amount of funding available, this sounds like a generous offer. This offer to transfer gives Malala’s family members some more time to process the reality of the situation, and also relieves the hospital from continued expenses. Still, the likelihood of a recovery is slim to none so this option is still going to produce an unnecessary expense.        

One health care provider recommended that the hospital form a panel to help choose the appropriate course of action in Malala’s case. Since more than one person or entity has a say on how to proceed in this case, I agree that arranging a panel would be a good start. This would allow all parties involved to present their views on the problem, identify ethical values and principles at stake, identify all involved or potentially involved parties, and discuss solutions and weigh their potential benefits or consequences. Many hospitals have clinical ethics committees (“CECs”) to assist in making these difficult decisions. These committees are usually comprised of medical doctors, hospital administrator or representative, hospital Chaplin, nurses, and an external consultant (a physician) with formal training in medical ethics. In Malala’s case, it might be a good idea to involve a family member in this discussion as well in order to help them understand the reasoning behind each recommendation.



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