The ethics of cost for cure vs noncompliance.

This is just a hypothetical discussion, but we all know the scenario is all too real.

Let's say you have a patient whose Hep C is causing kidney and heart problems. There is now a cure for Hep C, but it is very costly, and the patient must take the med along with others religiously to be effective. You are the nurse for the patient, and you are overhearing the conversation between the docs and the patient about the new medications that they are on. The patient tells the docs, "Oh, yes, I will take them!" However, in the three days that you've had the patient, the only med he has taken--and actually asked for on time--are the narcotics. All other meds, including lasix, the patient initially refuses, and you spend much time educating and persuading the patient to take them. With the docs in the room, you say to the patient, "Are you sure you are going to follow the medication plan? You have tried to refuse all your meds every time I've administered them to you." You do it because you want the docs to be aware that there is an issue with noncompliance.

The docs are thinking of prescribing Sovaldi to cure the Hep C in order to address some of the kidney and heart problems too. You are convinced that the patient will not follow the strict medication regimen for Sovaldi, and you also know the cost of the full treatment can be more than $150k.

Two questions: what would you do to help ensure that, if the patient is prescribed Sovaldi, that he will be compliant?

Also, a more philosophical question: if there is evidence of noncompliance with medications, SHOULD a patient be prescribed a very costly medication that can cure them, but probably won't due to the chronic noncompliance?
Who would be paying for this treatment? I wouldn't be surprised if they make him jump through hoops. It seems if he could do a 24 week treatment and be done and healthier it's worth it. I wonder if counseling or something like that might help his compliance?

Don't those receiving organ transplants have to demonstrate a willingness to comply with treatment before a transplant can procede?Is that because the transplant is costly? Or is it because there aren't enough organs? Or is it both?I'm going out on a limb, but I would be in favor of restricting treatment for patients who are of sound mind, and refuse to participate in their own health care. If sounds brutal, but why waste millions of dollars on people who themselves don't care if they live or die?If we can do it for transplant patients, and nobody thinks that's wrong, why not for the patient who is chronically noncompliant?I've already thought of an example patient to test my resolve..The COPD er who just can't get off the cigs. Multiple drugs, therapies, and family interventions have failed to help them stop smoking. THEY JUST CAN"T QUIT. Do we stop admitting them to the hospital and let them die?It's not an easy question.

I remember two theories of resource utilization from ethics class during nursing school, don't remember their names but one was about being benevolent and the other being practical. I'm all the way for what you reap, what you sow, so believe that the non-compliant should be given no eternal second chances wasting our valuable tax money that can go to helping people who will comply.

Interesting viewpoints, and as in most ethical situations, there really isn't a "right" or "wrong" answer...there's just an answer that more people are ok with. I don't know the answer myself, but your thoughts on it are appreciated. I'm still mulling it over, of course.

Quote from imintroubleDon't those receiving organ transplants have to demonstrate a willingness to comply with treatment before a transplant can procede?Is that because the transplant is costly? Or is it because there aren't enough organs? Or is it both?I'm going out on a limb, but I would be in favor of restricting treatment for patients who are of sound mind, and refuse to participate in their own health care. If sounds brutal, but why waste millions of dollars on people who themselves don't care if they live or die?If we can do it for transplant patients, and nobody thinks that's wrong, why not for the patient who is chronically noncompliant?I've already thought of an example patient to test my resolve..The COPD er who just can't get off the cigs. Multiple drugs, therapies, and family interventions have failed to help them stop smoking. THEY JUST CAN"T QUIT. Do we stop admitting them to the hospital and let them die?It's not an easy question.

Quote from Ruby VeeMost hospitals where I have worked only do a cursory check for compliance before Oking a transplant. There can be documented compliance issues over and over and they'll still transplant the patient because "he promised he'd do better." Active smokers have been given heart or lung transplants because "he promised he'd quit." An active IVDA-er was transplanted because "We translanted a male with this issue, it's gender bias if we don't go ahead and transplant HER despite this problem." A hospital where I've worked in the past transplanted illegal aliens, even though one of the boxes to be checked off before transplant is "no pending legal issues." Health care in this country costs more than anyplace else in the world. (Or near enough as to be a real problem.) Part of it is because we don't deny anyone anything regardless of ability to pay.) The Crushing Cost of Health Care - WSJThis is an enlightening article!

Quote from Ruby VeeMost hospitals where I have worked only do a cursory check for compliance before Oking a transplant. There can be documented compliance issues over and over and they'll still transplant the patient because "he promised he'd do better." Active smokers have been given heart or lung transplants because "he promised he'd quit." An active IVDA-er was transplanted because "We translanted a male with this issue, it's gender bias if we don't go ahead and transplant HER despite this problem." A hospital where I've worked in the past transplanted illegal aliens, even though one of the boxes to be checked off before transplant is "no pending legal issues." Health care in this country costs more than anyplace else in the world. (Or near enough as to be a real problem.) Part of it is because we don't deny anyone anything regardless of ability to pay.) The Crushing Cost of Health Care - WSJThis is an enlightening article!

Quote from tarotaleLove your post! Exactly what I think. It's engraved in this culture that Healthcare is a right. Choice to live healthy is a right, but Healthcare is a privilege, a service which is bought with monetary responsibilities. Yes we should help some indigent as a society but when that goes beyond normal spectrum, we get this. I'm curious whether or not this is due to the "stupid American syndrome". While the world thinks Americans are stupid and I agree this country holds proportionately more idiots than other countries, but would other 1st world countries whose people we deem "more with common sense" for example, Germany, Sweden, Norway, or Japan have similar problem due to noncompliance to this severity? Or do we as country just hold more dumb people making dumb decisions therfore affecting Healthcare even worse, or is it all just stemming from the fact that we are "too benevolent" to the freeloaders (frequent flyer, welfare milker, etc) ??? I don't know, working in healthcare really makes one exposed to how stupid people can be on daily basis.

I don't agree with "stupid" either. The USA is both first and third world. IMHO, any country that has been touched by a history of slavery will be at least partly third world. There is a lot of relative poverty and a certain mindset that goes with that. Noncompliance is a symptom of a poverty mindset.

Quote from Ruby VeeMost hospitals where I have worked only do a cursory check for compliance before Oking a transplant. There can be documented compliance issues over and over and they'll still transplant the patient because "he promised he'd do better." Active smokers have been given heart or lung transplants because "he promised he'd quit." An active IVDA-er was transplanted because "We translanted a male with this issue, it's gender bias if we don't go ahead and transplant HER despite this problem." A hospital where I've worked in the past transplanted illegal aliens, even though one of the boxes to be checked off before transplant is "no pending legal issues." Health care in this country costs more than anyplace else in the world. (Or near enough as to be a real problem.) Part of it is because we don't deny anyone anything regardless of ability to pay.) The Crushing Cost of Health Care - WSJThis is an enlightening article!

the example does not really have to be that extreme. I am a diabetes educator and have people tell me all the time they cannot afford their insulin or strips. Many, however, are carrying cell phones and smoking cigarettes, but the point is, they made the choice. I am for autonomy.

As the old saying goes, you can lead a horse to water...As an individual, it is frustrating that the cost of care is out of control and that some medications are abused, not used, or wasted by some people. But that is only part of the problem. The cost of HC in the US is astronomical in comparison to other industrialized nations. Our system does not negotiate for the best rates on supplies, prescription medications, etc. Most other nations do, and their costs are measurably lower. Much lower. And they also have non-compliant patients.Americans do not have equal access to the full range of healthcare services offered in this country. Many generations have been raised without medical or dental care, or have not had equal access to quality education, quality foods, or quality support services. This, combined with other cultural and socioeconomic factors, results in the patient that is sitting in front of you who won't take their meds. And even those who have had access to everything, and have enjoyed the benefits of prosperity, will sometimes be non-compliant with their meds. I am certain that psychology and denial have a great deal to do with it.Every individual must be free to make their own choices about their health and their body. My job as a nurse is to teach. If there are resources available to help with compliance, such as social services/psych services, it is my job to help with the referral. What the patient does with the teaching and referrals is up to them, and I would not support withholding medications. The patient may get an 'ah ha' moment, and if they have a condition that requires medication, the condition itself will force their hand, or take their life. My job is to try to convince them to take the better path.Diabetes is a great example. So is heart disease, or lung disease (and a host of other conditions). Exercise, nutrition, stress management, medication, lifestyle (no smoking, no drinking), etc., are all components of managing health. How many of us in the nursing profession even meet the ideal standard for our own lives? Organ transplantation is a different story. The ability to take daily anti-rejection medication for the rest of your life is key in a health area where the supply never meets the demand. I think that is an entirely different issue than the one proposed by the OP.