Most of my patients are low-income and receive Medicaid or similar assistance. What moral and ethical responsibilities do I have to patients requesting referrals and prior authorization for such things as eyeglasses or fertility treatment, gastric bypass, and other elective procedures? I am hesitant to ask the state to pay for these things when the system is so overwhelmed with patients facing much more urgent problems.
—Richard Hobson, PA-C, Globe, Ariz.

Start by setting aside the issue of the morality of a two-tiered health-care system and focus on the individual patient. Next, review the four principles of medical ethics—autonomy, beneficence, nonmaleficence, and justice.

Respect for patient autonomy means that clinicians obey the patient’s desire and decision regarding his body. If the patient requests and meets the criteria for gastric bypass, it is the clinician’s duty, based on this principle, to refer the patient for that service.

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Beneficence obligates clinicians to make decisions that are best for the patient, without regard to personal gain or the interests of others. Again, the patient should be referred for the requested procedure.

Nonmaleficence requires that clinicians not make decisions resulting in harm. Is the patient or anyone else harmed by offering the referral? With regard to the issue of scarce resources, it can be argued that the patient in need of a lifesaving transplant would be harmed if only one referral was possible and it went to the patient who requested fertility treatments.

The principle of justice requires clinicians to do what is fair. This includes following the law when making decisions. If the law allows the referral, then it should be offered.
—Jill Reichman, MPH, PA-C, associate director, University of Medicine and Dentistry, New Jersey, Physician Assistant Program, Piscataway (101-10)