Case Management Insider

An ethical dilemma found in a case study

By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

I will never forget my biggest ethical dilemma. It happened when I was a director of case management at a large medical center in New York City. It was the day after Thanksgiving. I was at work, but a lot of people in administration were off that day. I received a page from the director of critical care medicine. He was covering the ICU that day and wanted to transfer a patient to our hospital from another state.

I knew the patient he was referring to, because the patient recently had been in our hospital for a six-month length of stay, and the patient's discharge plan had been difficult and complex. The doctor explained to me that the patient had been readmitted to a hospital in another state, but that his wife wanted him to return to our hospital because she knew the nursing and medical staff and felt more comfortable there. The doctor wanted the patient in our hospital too, because he felt it was "the right thing to do for the patient" and would improve continuity of care.

Since I knew the patient and his wife, and I also knew that the admission would be out-of-network and probably not reimbursable, I found myself faced with a classic organizational, or case management, ethical dilemma. I explained to the doctor that the transfer would not be approved by the patient's managed care insurer, as the care the patient required could be provided at an in-network hospital. I was concerned that the patient would have another long stay, entirely without payment to the hospital. The doctor understood my concerns, but he wanted to put the needs of the patient and his wife above those of the hospital. In this classic conflict, he was exhibiting beneficence. Beneficence is defined as an ethical principle that directs the healthcare professional to take action to promote the well-being of his or her patients. (For a list of terms most commonly applied to case management, see, below.)

Dictionary: Common Ethical Principles Applied to Case Management

  • Autonomy: A form of personal liberty of action in which the patient holds the right and freedom to select and initiate his or her own treatment and course of action.
  • Nonmaleficence: Refraining from doing harm to others.
  • Justice: Maintaining what is right and fair and making decisions that are good for the patient.
  • Distributive justice: Deals with the moral basis for dissemination of goods and evils, burdens and benefits, especially when making decisions regarding the allocation of healthcare resources.
  • Veracity: The act of telling the truth.

Source: Cesta T, Tahan H. The Case Manager's Survival Guide: Winning Strategies for Clinical Practice. Second Ed. St. Louis, MO: Elsevier Health Sciences; 2003.

I, on the other hand, was advocating for a decision that addressed the financial needs of my employer, the hospital. However, since my decision had a direct impact on the patient, the patient's wife, and the potential quality of care of the patient, I found myself faced with a difficult decision. Without anyone to share the decision-making burden with me, I considered the wishes of the patient's wife against the financial needs of the hospital. In my initial response to the physician, I denied the admission and cited the financial risk at hand and the potential non-reimbursement to the hospital.

Needless to say, the physician was not happy with my decision and provided me with a list of reasons why I had made the wrong decision. His beneficence was front and center! I considered his argument, as well as what I had told my case managers and case management students many times: "when in doubt, err on the side of the patient. If you do this, no one can fault you for your decision."

I finally agreed to the transfer. The outcome was not pretty. The patient came to our hospital that day. He stayed in acute care for several months and ultimately was transferred to our acute rehab unit. The entire stay was nine months. And we got paid for none of it.

So, ask yourself. What would you have done in this situation? Perhaps, if I'd had an organizational ethics committee and could have taken my dilemma to them, the outcome might have been different. Even if it hadn't been different, at least I would have had the power of the committee behind me to support my decision.