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Assessing hospitals' responsibility to provide unremunerated services
FEATURE ARTICLE
Assessing hospitals’ responsibility to provide unremunerated services by Carolyn Ells Carolyn Ells, PhD, is an Assistant Professor of Medicine and member of the Biomedical Ethics Unit at McGill University, and Clinical Ethicist at Sir Mortimer B. Davis Jewish General Hospital (JGH). She chairs both the Clinical Ethics Committee and Research Ethics Committee at JGH. Her research addresses topics in organizational ethics, clinical ethics, research ethics and autonomy theory.
Abstract Hospitals typically absorb the costs of unremunerated health care services; however, budget cuts make this no longer feasible. This article identifies important ethical and legal dimensions of a hospital’s duty regarding unremunerated services in a climate of scarce resources. While, except in certain emergency situations, a hospital has no obligation to provide services to those who cannot pay, some guidelines are offered to help hospitals respond to requests for unremunerated services.
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nremunerated hospital services are patient care costs that hospitals absorb without compensation. In essence, the hospital pays medical bills on behalf of patients who cannot pay for the health care services they receive.1 This is a growing problem for Canadian hospitals, particularly in communities that attract large numbers of immigrants, refugees, illegal aliens and foreign visitors. Facing costs of $2 million annually in unremunerated services would not be unusual in many Canadian tertiary hospitals. Even in hospitals where such costs are not as high, funds are no longer available to cover substantial unremunerated services without interfering in the ability to provide services to those who can pay for what they receive, from either public or private means. Where hospitals have managed to absorb these costs in the past, substantial budget cuts and the increasing costs of unremunerated services make this practice prohibitive. As a result, health care professionals, including health service executives, are confronted with a number of ethical and legal concerns about the degree to which hospitals should allocate resources to patients who cannot pay for them. The location of care (whether in the Emergency Department, in-patient ward, or out-patient clinic) is not in itself indicative of the level of services received or costs required. Persons can receive unremunerated services in the Emergency Department and be discharged home or to another acute care institution; persons can be hospitalized for elective care; urgent care can be delivered in out-patient settings. The interplay between personal, professional and social values and expectations, how one understands the mandate of the institution and one’s role in relation to it, legal responsibilities, the uncertainties inherent in medical practice, and the potential consequences to patients, hospitals and health care professionals should all contribute to how one addresses unremunerated services. This article identifies and analyzes important ethical and legal dimensions of a hospital’s duty regarding provision of unremunerated health care services in a Canadian climate of scarce resources. Legal, ethical and jurisdictional considerations are reviewed, and discussed and analyzed with the help of case examples. Guidelines are proposed to help health care professionals, including health service executives, to address these situations. The focus here is on the responsibility of hospitals. Nevertheless, in addition to costs absorbed by hospitals, it is important to realize that unremunerated services typically also result in loss of income for physicians who
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are not on salary. While some physicians may choose to provide pro-bono care to those who seek their services, in doing so, a domino effect can occur. Ordering further tests and treatments requires specialists and sub-specialists to decide whether they, too, will provide “pro-bono” services (if they realize they will not be paid prior to providing the requested services). This situation can cause animosity among physicians, which can put at risk collegial and cooperative working relationships particularly when the situation recurs with some frequency. It can also affect waiting times and resource availability for other patients seeking health care services. People who request and/or receive unremunerated care People who request and/or receive unremunerated health care services are typically visitors, illegal aliens, refugees who have not applied for or received medicare coverage, international students with insufficient health insurance coverage or Canadian citizens who temporarily do not qualify for medicare (e.g., recently returned from living abroad and did not obtain private health insurance coverage for the interim period before qualification for medicare resumes). In many, if not most, instances, people seeking these services do not deliberately set out to take advantage of the Canadian health care system, or cost it large sums of money. Circumstances, some chosen and some imposed, put people with insufficient personal resources in need of health services and the best or easiest solution is to seek free care in a nearby Canadian hospital. Representative cases include: 1. Joanna, an international student, is diagnosed with active Tuberculosis (TB). Because her active TB poses a public health risk, she is admitted to hospital for a sixweek course of treatment. She explains that, because she was ill, she did not register for courses this semester. The hospital learns that because she is not registered for full-time studies, her health insurance coverage is nullified. She cannot pay her bill. 2. Deryek visits friends in Canada. He drowns in their pool and is sent to the hospital by ambulance. Following resuscitation, he is in a coma. His family is anxious to have him transported home to the United States, but must wait two weeks for him to stabilize medically. His health insurance does not cover out-of-country travel. 3. Leah has come from Asia to visit family in Canada. She soon arrives in the Emergency Department with an irregular heart rate, but is unable to pay for health care services. Although admission to CCU is deemed usual practice, two cardiologists agree that it is not essential. She is stabilized and discharged with the recommendation that she return to her home country where treatment is available to her. She is told that she will need surgery in the future because of her condition. Leah makes it clear that she will remain with her family in Canada indefinitely.
Legal considerations According to Canadian negligence and malpractice laws, a patient-physician relationship must exist for a physician to have a duty to provide health care services to a particular person (i.e., “duty of care”). The law does not oblige a physician to establish a patient-physician relationship and duty of care with a person who presents himself/herself to the physician for health care services. Yet, a “duty of rescue” may apply to a physician in a health care setting (such as a hospital or clinic) to intervene with health care services if someone’s life or integrity of person is in danger, regardless of that person’s ability to pay for the services.2 Likewise, a hospital can legally refuse care to an uninsured person who cannot provide a satisfactory financial guarantee, except if the life or integrity of that person is in danger.3 Regarding the civil responsibility aspect of this question, a hospital is not at fault in refusing to care for an uninsured person who cannot provide a satisfactory financial guarantee, except if the life or integrity of that person is in danger.4 With regard to unremunerated services, a Canadian publicly administered hospital only has a legal obligation to provide unremunerated services to a person when his/her life or integrity is in danger. Understanding and abiding by this legal “bottom-line” is largely straightforward. But this does not resolve the ethical dilemma regarding how much (if any) non-emergency unremunerated service to make available. For example, in many cases the actual costs are often marginal, because fixed costs such as overhead and salaries are not affected and few supplies and tests are needed. Also, the costs can be lower (and health benefits higher) when services are provided before a true emergency exists. Should a hospital intervene to help these people? Sometimes compassion seems to warrant providing health care services. Another legal requirement is relevant to this issue. Many Canadian hospitals now have fiscal management requirements set by their provincial governments that make balancing their budgets a legal requirement. The potential consequences of breaching this obligation must be factored into a hospital’s handling of unremunerated services. Even when the cost of each case is low, the expense adds up and can still have a significant effect on fiscal management. Even when a hospital can cope with the cost of (at least some) unremunerated services, the question remains: Should they provide it, or should their funds be put to a different use? An ethical analysis cannot be avoided. Ethical considerations Institutional mission and values Typically, a hospital’s mission and values statements will not mention unremunerated services, nor will their policies specifically address this issue. Yet, a hospital’s mission and values statements generally indicate, among other things, that it is committed to compassion and responding to patient needs. Hospitals commonly claim to strive to provide outstanding patient care, to act with social concern, and to manage their resources responsibly. Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2006
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Who may be considered a “patient of the hospital” will have bearing on who will be entitled to receive its services. It is reasonable to assume that a “patient of the hospital” is someone who is formally admitted to the hospital or receives treatment as an out-patient. Requesting that health care services be provided is insufficient to guarantee a right to receive those services (except when the life or integrity of the person is in danger). Similarly, hospital admission is also insufficient to guarantee that any service requested should be delivered. Good medical judgment, responsible use of resources, hospital policy and ethical and legal considerations all are essential to the development of any care plan. Likewise, it is reasonable that the patient’s ability to pay for services being considered be factored into care planning, just as it is when planning rehabilitation or management of illness in the post-hospital period for other patients. Augmenting mission and values statements, and codes of ethics of the hospital and/or its health care professionals, a hospital’s strategic planning documents and accreditation requirements provide additional guidance for prioritizing use of resources. At this level of planning and guidance, there is (rightly) a focus on the needs and interests of populations (as opposed to individuals) served by the hospital. Neither strategic planning nor accreditation guidelines are likely to contribute directly to resolving dilemmas about specific individuals seeking unremunerated services. Indirectly, accreditation standards that require institutional mechanisms for handling ethical challenges5 support in principle a hospital’s responsibility to assist its health care professionals in situations of moral uncertainty, conflict and distress, which can include situations involving unremunerated services. Sources of assistance can involve education, hospital policy, and/or other action. One could claim that such support are also justified by the need to ensure that the hospital’s mission and values are enacted. Professional values Health care professionals, including health service executives, are bound by the codes of ethics of their professional groups. Reflecting the broad responsibilities of hospital leadership, the code of ethics for the Canadian College of Health Service Executives requires its members to assist the organization to “serve the public interest” and “strive to provide high quality services within the resources available.” In partnership with the community and society, Canadian health service executives are responsible to “strive to identify and meet the health needs of the community.”6 While the emphasis for hospital leadership is the needs and well-being of the population it serves, most codes of ethics for health care professionals (who are assumed to work directly with patients) stipulate a priority to the needs and interests of individual patients. Yet, there is also a clear directive for health care professionals to use social resources responsibly.7,8 It is reasonable to conclude that these professional values support a claim that health care professionals working directly with patients or at the level of hospital leadership ought to attempt to provide good patient care, within 8
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the resources available, taking into account the population served by the hospital. In deriving, and understanding, this obligation one can make use of the philosophical principle of “ought implies can.” In other words, health care professionals are not obligated to provide resources that are not available to them. Codes of ethics for physicians typically indicate that an established relationship of care with a patient contributes to a physician’s responsibility to continue that care relationship unless the patient can be safely transferred.7,9 Most physicians take this obligation very seriously. Thus, if a therapeutic relationship exists before an inability to pay for services is made known to the physician, then the physician is likely to feel a professional obligation to continue to provide care if alternative funding arrangements or care arrangements cannot be made. Almost by definition, alternatives that are satisfactory to both health care professionals and seekers of services will not be available in most situations where care is requested or provided to someone who cannot pay for it. For example, a physician cannot easily discharge patients ineligible for medicare to community health services for follow-up care. Some physicians will provide limited unremunerated services; many do not. Many, but not all, physicians in hospital settings assume that a therapeutic relationship is established when someone presents to the hospital seeking care, or is referred to a physician for care. Nevertheless, physician codes of ethics allow: “A physician may put an end to a therapeutic relationship when there is a reasonable and just cause to do so.”9 Given the legal considerations (discussed earlier), it is reasonable to consider an inability to pay for non-emergency health services a just cause for ending, or not starting, a therapeutic relationship. It is natural in a universal, publicly administered health care system such as exists in Canada that the codes of ethics of health care professionals not address the issue of people who seek services to which they are not entitled. Codes of ethics are designed to name the responsibilities that health care professionals have with regard to their patients, colleagues and society. “Responsibilities” that they do not have are not addressed, nor are the needs and interests of people not eligible to be included in that universal, publicly administered health care system. Canadian values about health care In her historical analysis of public support for Canadian social legislation, Barbara Murphy10 reports that as early as 1950, Canadians embraced the notion of health insurance. Large numbers of Canadians had enrolled in voluntary health insurance plans, and a Gallop poll found that 80% of Canadians wanted a government-funded health insurance program. This was before federal and provincial governments declared an interest in creating national or provincial health plans. Canadian governments responded to the Canadian public (albeit with considerable struggle, and resistance from Canadian physicians) and by 1961, health care benefits were available to nearly the entire population of Canada.
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The principles of the Canada Health Act – public administration, comprehensiveness, universality, portability and accessibility – underscore many values that Canadians continue to hold about their health care system. These principles and this Act are explicitly restricted as to how the national health insurance plan is to be governed. For example, “accessibility” refers to reasonable access by insured persons to medically necessary hospital and physician services unimpeded by financial or other barriers.11 It does not provide for “free” health services to those not insured in the system, nor does it provide for services beyond medically necessary hospital and physician services. In 2002, two extensive assessments on the health and health needs of Canadians, by the Honourable Michael J.L. Kirby12 and Roy J. Romanow,13 identified continued support for the values and principles of the Canada Health Act. Recommended changes to the Act (and provision of health services generally) deal with how those values and principles are applied. Neither report addresses unremunerated services. The 1997 National Forum on Health,14 in surveying Canadians about their health care system, revealed the following Canadian core values: equality (or fairness), compassion, dignity and respect, efficiency/effectiveness, collective responsibility, personal responsibility, quality and responsible stewardship (accountability). These values complement those underlying the Canada Health Act principles, likewise suggesting their ongoing relevance for Canadians. Nevertheless, in recent years several Canadian social programs, including health insurance programs, have been waning in public support. The Canadian Medical Association and others have called for revisions to the Canada Health Act such that those who can afford it will pay for at least some of their health care services.10 Moves to opt out of government health insurance programs (particularly in Alberta and Quebec) have sparked public and political debate. Both individual and government efforts to provide assistance to those in need are generally valued and admired by Canadians. Some feel that good citizenship and good government carry an obligation to provide at least some unremunerated services. However, lack of public and political discussion on the issue of unremunerated health services suggests that there is no widely held social expectation to provide hospital or physician services to non-medicare-insured persons. Given the scarcity of resources available to the Canadian health insurance program, and recent discord among Canadians about what set of health care services should be provided to those within public insurance programs, one could reasonably question the justification for providing any public health care services to those ineligible for Canadian public health insurance, even responding to emergency health needs of those not covered (although I do not make this argument here). Distributive justice There is no agreement in the scholarly literature or in widespread practice about what principles should guide in
distributing scarce health care resources or which take precedence if more than one principle seems to apply, but being guided by seemingly applicable principles yields incompatible courses of action. Principles of liberty, utility, need, benefit, merit, equality, efficiency, responsibility, ability to pay, fidelity to patient, restitution, first come first served and other procedural principles of justice are used in different situations.15-18 Often, health care professionals consider several of these principles. For example, a physician might consider primarily need and efficiency in determining how to allocate time with patients when rounds must be cut short. Similarly, there is no agreement about how much we should favour producing the best outcomes with limited resources, how much priority should be given to treating the sickest or most disabled people, when modest benefits to a large number of people should outweigh more significant benefits to fewer people, or when we should rely on a fair democratic process to determine what constitutes a fair rationing outcome.19 Decisions about allocation of resources occur at different levels (macro=government, meso=institution, micro=individual). Different responsibilities, and hence different values/principles, may apply or be weighted differently at different levels. For instance, the needs of populations mandated to serve properly have more weight when setting government and institution policy about allocating and rationing resources (e.g., how much resources to put towards cancer care, radiology services, and other treatments), whereas greater emphasis can be given to the needs of particular individuals when allocating or rationing between individuals (e.g., prioritizing who is seen by the Emergency Department physician, who receives dialysis and so on). Given the scarcity of resources available to Canadian hospitals, a hospital is justified in using distributive justice in allocating resources to people who have, or are eligible for, medicare coverage. Relevant criteria should be developed to guide distribution of limited resources, where possible. Yet, some flexibility among criteria is warranted, as some principles or prioritizations may be deemed more relevant (justified) in some situations over others. For example, inability to pay (for non-emergency treatment) should have great sway in denying health services when the foreseen costs to the hospital (or physicians) is so great as to bring harm to others who have a greater claim to those resources. Yet, inability to pay may be less applicable when foreseen costs to the hospital are low while other principles are compelling. For example, a tourist is injured when she tries to help a mugging victim near the hospital. A health service executive deems that compassion, restitution and benefit justify providing services that will have only minimal effect on hospital resources. A hospital should establish a governing process that demonstrates accountability, when the identification and weighing of relevant principles of justice yield uncertainty or the application of other hospital policies does not solve rationing questions. This process should be ongoing so that Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2006
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efficacy and effectiveness are maximized and relative consistency is achieved in decisions made. The process should include four elements: transparency of decisions and their rationales, rationales that give a reasonable explanation of how the decisions fulfill social or organizational objectives within resource constraints, a mechanism to appeal decisions or policy, and regulation of the process to ensure these conditions are achieved.20 Persons involved in the establishment of a decision-making accountability process should include the Chief Medical Director (Director of Professional Services), the Chief Financial Officer, representatives of health care professionals who are confronted with choices about whether and how to respond to requests for unremunerated services, and one or more persons who can represent the perspective of people seeking unremunerated services. Jurisdiction considerations It can be expected that provincial governments will resist compensating unremunerated health care as responsibility for the health care of non-citizens (or non-medicare-eligible persons) lies beyond its jurisdiction. From a practical point of view, it is reasonable to predict that a government willing to regularly provide health care services to people who cannot pay for those services will quickly be flooded with large numbers of non-paying and non-medicare-eligible people seeking health care services. This would quickly overwhelm and bankrupt the system to the ire and detriment of Canadians. While setting up special government funds to assist those not eligible for medicare to pay for health services is not a promising alternative, special interest groups may choose to develop charitable funds with access criteria to be used on either an ad-hoc or regular basis for health care services that would otherwise be unremunerated. Discussion In light of these considerations, let us return to the cases presented earlier. In Case 1, Joanna is an international student diagnosed with active TB. Her condition poses a public health emergency, which led to her admission to hospital for a six-week course of treatment. Were options other than “treat free of charge” or “not treat” considered? For instance, is it possible for Joanna to register for university courses late in order to reactivate her health insurance? Can a flexible payment schedule be arranged, perhaps at a reduced rate that waives fixed costs such as overhead? Would the risk to public health be avoided if Joanna wore a mask that filters the TB virus, and returned to her home country (where she hopefully receives treatment)? Decision-makers should compile as complete a list of potential courses of action as possible, before assessing the merits of each option and making a choice. For health care professionals, this means weighing options that usually are not considered, so other interested parties should be involved to help identify and assess possible courses of action. If sending Joanna out of the country is
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not a viable or justified option, and alternative funding is unavailable for her, the hospital may have no choice but to absorb the cost of her care to protect the public (if not Joanna herself) from the morbidity and mortality of TB. Joanna’s situation is complicated by the details of her health insurance policy. Her insurance is void if she is not registered for classes as a full-time student. (Her immigration status may be similarly jeopardized.) A university that admits an international student and the immigration department that issues a student visa bear some responsibility for reasonable oversight such that the student does not place an undue financial or health burden on the Canadian public. Accordingly, there should be minimum standards for health insurance policies (that include hospital care), and oversight of compliance with health insurance criteria (including registration for classes if health insurance hinges on it). Acting in good faith, some people purchase travel health insurance policies assuming that hospital services are covered by these policies. Hospitals can learn too late, that is, after a patient is discharged and the insurance company rejects the bill, that the insurance does not cover services received. Unless the hospital can contact these former patients and receive payment, the expenses must be written off. If this is a recurring problem, a hospital may benefit from a change in process to assess insurance policy coverage prior to treatment commencement or earlier in a hospital stay. In Case 2, Deryek presents to the hospital in a medical emergency, having drowned in a friend’s pool. Hospital intervention is clearly required to restore his life. Resuscitation leads to coma and the need for two weeks of interventions to stabilize his condition. Too unstable for transport, Deryek’s condition remains a medical emergency and the hospital is obligated to provide treatment, regardless of his inability to pay. Once stabilized, if alternate sources of funding are not forthcoming, it may be in the hospital’s financial interest to arrange for and pay to transfer Deryek to a facility that meets his needs in the United States. Although Deryek lives in one of the southern states and his family prefers that he be flown back to his home state, the hospital is obligated only to transfer him to a facility that meets his basic health needs. Since there is a hospital that accepts Deryek’s health insurance in a border state only three hours drive from the Canadian hospital where Deryek lies in a coma, health service executives meet their obligation to Deryek by arranging safe transfer to that location. In Case 3, Leah arrives in the Emergency Department where an irregular heart rate is discovered. It is not clear whether her initial condition should be classified as “emergency” or “urgent.” Sometimes tests and an assessment of response to initial interventions are needed before classifying a condition is possible. Sending Leah from the hospital without assessing her cardiac status would be inappropriate as it could violate the obligation to treat medical emergencies. If she were assessed to have an urgent (not emergency) condition, sending her away without treatment also seems
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problematic, because untreated urgent conditions can often escalate into emergency conditions, which in her case may be more difficult to treat successfully. Furthermore, some stabilizing treatment is available without unduly jeopardizing the health care resources available to others. Thus a favourable ratio of potential benefits to potential harms exists that takes into account not only Leah but also others who have a stronger claim to hospital resources. Leah’s case exemplifies a range that often exists in standards of care. Even though admission to the Coronary Care Unit for closer monitoring is usual practice at the hospital, cardiologists assess that adopting a lower than usual monitoring plan is still an acceptable practice since her situation is not an emergency. Perhaps she will be monitored as an out-patient (this may be acceptable if it does not stress hospital resources or the needs of other patients), or perhaps she will be given instructions to monitor her own condition. One factor of Leah’s case that is troubling is her rejection of medical advice to return to her home country where treatment is available. She rejects this advice even though heart specialists predict that she will need heart surgery in the near future. Is Leah not willing to take responsibility for her own health needs? Does she intend to abuse the generosity of Canadians by having emergency heart surgery if it comes to that? Does a principle of justice based on merit apply and reduce the hospital’s responsibility to act should she return in need of urgent or emergency heart treatment? As with any refusal of medical recommendations, Leah’s comments about not returning home for treatment should be explored. Perhaps she feels it is not safe to return home. Perhaps there are pressing issues involving her family in Canada that she believes take priority. A social services consult may be of assistance. Is there a social responsibility to provide a medical report to the Department of Immigration, which provided the visitor’s visa? Although hospitals are not usually involved in immigration issues, most seekers of unremunerated services are in the country at the discretion of immigration officials and can legitimately be deported (following due process) if they pose a threat to Canadians in terms of security or use of public resources. Health care professionals would need to assess whether there is a duty to protect confidentiality in this case. If a breach of confidentiality is necessary to avoid imminent harm, to identifiable others, which cannot be avoided by other means, and the harm avoided is greater than the harm caused by breaching confidentiality, then the breach is justified. If a breach is justified in Leah’s case, Leah should be informed of the intent to inform immigration and why. This step respects her dignity and might prompt a response from Leah to resolve the risk to others. Rationing decisions are rarely fully satisfying. For “rationing,” by definition, means that there are not enough resources available for all. People who need or could benefit from resources must do without. These are difficult decisions even when all potential recipients of the resources are undisputedly eligible to receive them. Making rationing decisions
that turn on “non-medical” factors (e.g., merit, costs or social consequences) may require basing decisions on at least some criteria that the decision-maker(s) does not have the expertise to assess. Given the values of Canadian health care professionals, and the inherent uncertainties of medicine and assessments of risk, it is reasonable to assume that, where responsible use of resources allow, requests for unremunerated services should be assessed case by case, taking into account individual needs, potential harm to others, compassion and resource availability. Proposed guidelines Based on the above analysis, the following guidelines may assist health care professionals or health service executives to respond to requests for unremunerated health care services. Emergency situations – In an emergency, care needed to sustain the life or integrity of the person must be provided. Urgent, routine or preventative services – There is no legal obligation to provide urgent, routine or preventative care. However, where responsible use of resources allow, requests for unremunerated services should be assessed compassionately, rather than being automatically rejected, as the situation and context of the person may justify providing some measure of health care delivery. Institutional guidance – Institutional policy should be established to assist health care professionals to respond responsibly in situations of providing or refusing unremunerated care. The policy should include identifying principles of justice (rationing) that will have priority in certain types of situations and a process to follow in all other cases, or when extenuating circumstances may apply. Given the complexity of the issues, an multidisciplinary approach may be needed. Accountability process – A process should be established that demonstrates accountability in decisions and practices about providing unremunerated services. The process should include transparency of decisions and rationales that explain how the decisions fulfill social or organizational objectives within resource constraints, a mechanism to appeal decision or policy, and regulation process. Identification of alternative sources for care and financial assistance – Accessible sources of health care delivery and/or funding may be difficult for people to identify or obtain. If possible and practical, people requesting unremunerated services should be directed to alternative sources such as: return to country of citizenship for health care taking into consideration the means to return safely and availability of care; community-based services; aid organizations; insurance plans where health care expenses are covered and the person repays the debt to the insurer.
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Standard of care in exceptional cases – In providing health care services, health care professionals have a professional obligation to provide competent care in conformity with professional standards of care. While no negligent care should be provided, it is important to acknowledge a range of accepted standards of care. It is acceptable to provide unremunerated health care services that are less than what would typically be provided to Canadian citizens, as long as the service is within accepted professional standards of care. Flexible payment options – Many hospitals provide flexible payment schedules on a case-by-case basis when unremunerated services are provided or negotiated. This practice should be continued.21 Where providing services is deemed justified bills may be adjusted to forgive or write off fixed costs but require payment for other costs. Respect for dignity – The dignity of persons requesting or receiving unremunerated care should be respected. Even when services are denied, all communication of decisions, rationales and suggested alternatives should be respectful. Partnership with local and government institutions – Local hospitals should work in partnership with government institutions to help resolve practice uncertainties and inconsistencies of unremunerated services,22 and to solve some of the impediments to accessing health care services (e.g., to require international students to have health insurance that covers hospital services).
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Acknowledgments The analysis and guidelines proposed in this article benefited from discussions with, and feedback from, Jane Chambers-Evans and members of the Clinical Ethics Committee at the Sir Mortimer B. Davis Jewish General Hospital. The author is grateful to Jessica Merkel-Keller for research assistance and the Social Sciences and Humanities Research Council of Canada for financial support of this research.
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Assessing hospitals’ responsibility to provide unremunerated services by Carolyn Ells Carolyn Ells, PhD, is an Assistant Professor of Medicine and member of the Biomedical Ethics Unit at McGill University, and Clinical Ethicist at Sir Mortimer B. Davis Jewish General Hospital (JGH). She chairs both the Clinical Ethics Committee and Research Ethics Committee at JGH. Her research addresses topics in organizational ethics, clinical ethics, research ethics and autonomy theory.
Abstract Hospitals typically absorb the costs of unremunerated health care services; however, budget cuts make this no longer feasible. This article identifies important ethical and legal dimensions of a hospital’s duty regarding unremunerated services in a climate of scarce resources. While, except in certain emergency situations, a hospital has no obligation to provide services to those who cannot pay, some guidelines are offered to help hospitals respond to requests for unremunerated services.
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nremunerated hospital services are patient care costs that hospitals absorb without compensation. In essence, the hospital pays medical bills on behalf of patients who cannot pay for the health care services they receive.1 This is a growing problem for Canadian hospitals, particularly in communities that attract large numbers of immigrants, refugees, illegal aliens and foreign visitors. Facing costs of $2 million annually in unremunerated services would not be unusual in many Canadian tertiary hospitals. Even in hospitals where such costs are not as high, funds are no longer available to cover substantial unremunerated services without interfering in the ability to provide services to those who can pay for what they receive, from either public or private means. Where hospitals have managed to absorb these costs in the past, substantial budget cuts and the increasing costs of unremunerated services make this practice prohibitive. As a result, health care professionals, including health service executives, are confronted with a number of ethical and legal concerns about the degree to which hospitals should allocate resources to patients who cannot pay for them. The location of care (whether in the Emergency Department, in-patient ward, or out-patient clinic) is not in itself indicative of the level of services received or costs required. Persons can receive unremunerated services in the Emergency Department and be discharged home or to another acute care institution; persons can be hospitalized for elective care; urgent care can be delivered in out-patient settings. The interplay between personal, professional and social values and expectations, how one understands the mandate of the institution and one’s role in relation to it, legal responsibilities, the uncertainties inherent in medical practice, and the potential consequences to patients, hospitals and health care professionals should all contribute to how one addresses unremunerated services. This article identifies and analyzes important ethical and legal dimensions of a hospital’s duty regarding provision of unremunerated health care services in a Canadian climate of scarce resources. Legal, ethical and jurisdictional considerations are reviewed, and discussed and analyzed with the help of case examples. Guidelines are proposed to help health care professionals, including health service executives, to address these situations. The focus here is on the responsibility of hospitals. Nevertheless, in addition to costs absorbed by hospitals, it is important to realize that unremunerated services typically also result in loss of income for physicians who
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are not on salary. While some physicians may choose to provide pro-bono care to those who seek their services, in doing so, a domino effect can occur. Ordering further tests and treatments requires specialists and sub-specialists to decide whether they, too, will provide “pro-bono” services (if they realize they will not be paid prior to providing the requested services). This situation can cause animosity among physicians, which can put at risk collegial and cooperative working relationships particularly when the situation recurs with some frequency. It can also affect waiting times and resource availability for other patients seeking health care services. People who request and/or receive unremunerated care People who request and/or receive unremunerated health care services are typically visitors, illegal aliens, refugees who have not applied for or received medicare coverage, international students with insufficient health insurance coverage or Canadian citizens who temporarily do not qualify for medicare (e.g., recently returned from living abroad and did not obtain private health insurance coverage for the interim period before qualification for medicare resumes). In many, if not most, instances, people seeking these services do not deliberately set out to take advantage of the Canadian health care system, or cost it large sums of money. Circumstances, some chosen and some imposed, put people with insufficient personal resources in need of health services and the best or easiest solution is to seek free care in a nearby Canadian hospital. Representative cases include: 1. Joanna, an international student, is diagnosed with active Tuberculosis (TB). Because her active TB poses a public health risk, she is admitted to hospital for a sixweek course of treatment. She explains that, because she was ill, she did not register for courses this semester. The hospital learns that because she is not registered for full-time studies, her health insurance coverage is nullified. She cannot pay her bill. 2. Deryek visits friends in Canada. He drowns in their pool and is sent to the hospital by ambulance. Following resuscitation, he is in a coma. His family is anxious to have him transported home to the United States, but must wait two weeks for him to stabilize medically. His health insurance does not cover out-of-country travel. 3. Leah has come from Asia to visit family in Canada. She soon arrives in the Emergency Department with an irregular heart rate, but is unable to pay for health care services. Although admission to CCU is deemed usual practice, two cardiologists agree that it is not essential. She is stabilized and discharged with the recommendation that she return to her home country where treatment is available to her. She is told that she will need surgery in the future because of her condition. Leah makes it clear that she will remain with her family in Canada indefinitely.
Legal considerations According to Canadian negligence and malpractice laws, a patient-physician relationship must exist for a physician to have a duty to provide health care services to a particular person (i.e., “duty of care”). The law does not oblige a physician to establish a patient-physician relationship and duty of care with a person who presents himself/herself to the physician for health care services. Yet, a “duty of rescue” may apply to a physician in a health care setting (such as a hospital or clinic) to intervene with health care services if someone’s life or integrity of person is in danger, regardless of that person’s ability to pay for the services.2 Likewise, a hospital can legally refuse care to an uninsured person who cannot provide a satisfactory financial guarantee, except if the life or integrity of that person is in danger.3 Regarding the civil responsibility aspect of this question, a hospital is not at fault in refusing to care for an uninsured person who cannot provide a satisfactory financial guarantee, except if the life or integrity of that person is in danger.4 With regard to unremunerated services, a Canadian publicly administered hospital only has a legal obligation to provide unremunerated services to a person when his/her life or integrity is in danger. Understanding and abiding by this legal “bottom-line” is largely straightforward. But this does not resolve the ethical dilemma regarding how much (if any) non-emergency unremunerated service to make available. For example, in many cases the actual costs are often marginal, because fixed costs such as overhead and salaries are not affected and few supplies and tests are needed. Also, the costs can be lower (and health benefits higher) when services are provided before a true emergency exists. Should a hospital intervene to help these people? Sometimes compassion seems to warrant providing health care services. Another legal requirement is relevant to this issue. Many Canadian hospitals now have fiscal management requirements set by their provincial governments that make balancing their budgets a legal requirement. The potential consequences of breaching this obligation must be factored into a hospital’s handling of unremunerated services. Even when the cost of each case is low, the expense adds up and can still have a significant effect on fiscal management. Even when a hospital can cope with the cost of (at least some) unremunerated services, the question remains: Should they provide it, or should their funds be put to a different use? An ethical analysis cannot be avoided. Ethical considerations Institutional mission and values Typically, a hospital’s mission and values statements will not mention unremunerated services, nor will their policies specifically address this issue. Yet, a hospital’s mission and values statements generally indicate, among other things, that it is committed to compassion and responding to patient needs. Hospitals commonly claim to strive to provide outstanding patient care, to act with social concern, and to manage their resources responsibly. Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2006
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Who may be considered a “patient of the hospital” will have bearing on who will be entitled to receive its services. It is reasonable to assume that a “patient of the hospital” is someone who is formally admitted to the hospital or receives treatment as an out-patient. Requesting that health care services be provided is insufficient to guarantee a right to receive those services (except when the life or integrity of the person is in danger). Similarly, hospital admission is also insufficient to guarantee that any service requested should be delivered. Good medical judgment, responsible use of resources, hospital policy and ethical and legal considerations all are essential to the development of any care plan. Likewise, it is reasonable that the patient’s ability to pay for services being considered be factored into care planning, just as it is when planning rehabilitation or management of illness in the post-hospital period for other patients. Augmenting mission and values statements, and codes of ethics of the hospital and/or its health care professionals, a hospital’s strategic planning documents and accreditation requirements provide additional guidance for prioritizing use of resources. At this level of planning and guidance, there is (rightly) a focus on the needs and interests of populations (as opposed to individuals) served by the hospital. Neither strategic planning nor accreditation guidelines are likely to contribute directly to resolving dilemmas about specific individuals seeking unremunerated services. Indirectly, accreditation standards that require institutional mechanisms for handling ethical challenges5 support in principle a hospital’s responsibility to assist its health care professionals in situations of moral uncertainty, conflict and distress, which can include situations involving unremunerated services. Sources of assistance can involve education, hospital policy, and/or other action. One could claim that such support are also justified by the need to ensure that the hospital’s mission and values are enacted. Professional values Health care professionals, including health service executives, are bound by the codes of ethics of their professional groups. Reflecting the broad responsibilities of hospital leadership, the code of ethics for the Canadian College of Health Service Executives requires its members to assist the organization to “serve the public interest” and “strive to provide high quality services within the resources available.” In partnership with the community and society, Canadian health service executives are responsible to “strive to identify and meet the health needs of the community.”6 While the emphasis for hospital leadership is the needs and well-being of the population it serves, most codes of ethics for health care professionals (who are assumed to work directly with patients) stipulate a priority to the needs and interests of individual patients. Yet, there is also a clear directive for health care professionals to use social resources responsibly.7,8 It is reasonable to conclude that these professional values support a claim that health care professionals working directly with patients or at the level of hospital leadership ought to attempt to provide good patient care, within 8
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the resources available, taking into account the population served by the hospital. In deriving, and understanding, this obligation one can make use of the philosophical principle of “ought implies can.” In other words, health care professionals are not obligated to provide resources that are not available to them. Codes of ethics for physicians typically indicate that an established relationship of care with a patient contributes to a physician’s responsibility to continue that care relationship unless the patient can be safely transferred.7,9 Most physicians take this obligation very seriously. Thus, if a therapeutic relationship exists before an inability to pay for services is made known to the physician, then the physician is likely to feel a professional obligation to continue to provide care if alternative funding arrangements or care arrangements cannot be made. Almost by definition, alternatives that are satisfactory to both health care professionals and seekers of services will not be available in most situations where care is requested or provided to someone who cannot pay for it. For example, a physician cannot easily discharge patients ineligible for medicare to community health services for follow-up care. Some physicians will provide limited unremunerated services; many do not. Many, but not all, physicians in hospital settings assume that a therapeutic relationship is established when someone presents to the hospital seeking care, or is referred to a physician for care. Nevertheless, physician codes of ethics allow: “A physician may put an end to a therapeutic relationship when there is a reasonable and just cause to do so.”9 Given the legal considerations (discussed earlier), it is reasonable to consider an inability to pay for non-emergency health services a just cause for ending, or not starting, a therapeutic relationship. It is natural in a universal, publicly administered health care system such as exists in Canada that the codes of ethics of health care professionals not address the issue of people who seek services to which they are not entitled. Codes of ethics are designed to name the responsibilities that health care professionals have with regard to their patients, colleagues and society. “Responsibilities” that they do not have are not addressed, nor are the needs and interests of people not eligible to be included in that universal, publicly administered health care system. Canadian values about health care In her historical analysis of public support for Canadian social legislation, Barbara Murphy10 reports that as early as 1950, Canadians embraced the notion of health insurance. Large numbers of Canadians had enrolled in voluntary health insurance plans, and a Gallop poll found that 80% of Canadians wanted a government-funded health insurance program. This was before federal and provincial governments declared an interest in creating national or provincial health plans. Canadian governments responded to the Canadian public (albeit with considerable struggle, and resistance from Canadian physicians) and by 1961, health care benefits were available to nearly the entire population of Canada.
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The principles of the Canada Health Act – public administration, comprehensiveness, universality, portability and accessibility – underscore many values that Canadians continue to hold about their health care system. These principles and this Act are explicitly restricted as to how the national health insurance plan is to be governed. For example, “accessibility” refers to reasonable access by insured persons to medically necessary hospital and physician services unimpeded by financial or other barriers.11 It does not provide for “free” health services to those not insured in the system, nor does it provide for services beyond medically necessary hospital and physician services. In 2002, two extensive assessments on the health and health needs of Canadians, by the Honourable Michael J.L. Kirby12 and Roy J. Romanow,13 identified continued support for the values and principles of the Canada Health Act. Recommended changes to the Act (and provision of health services generally) deal with how those values and principles are applied. Neither report addresses unremunerated services. The 1997 National Forum on Health,14 in surveying Canadians about their health care system, revealed the following Canadian core values: equality (or fairness), compassion, dignity and respect, efficiency/effectiveness, collective responsibility, personal responsibility, quality and responsible stewardship (accountability). These values complement those underlying the Canada Health Act principles, likewise suggesting their ongoing relevance for Canadians. Nevertheless, in recent years several Canadian social programs, including health insurance programs, have been waning in public support. The Canadian Medical Association and others have called for revisions to the Canada Health Act such that those who can afford it will pay for at least some of their health care services.10 Moves to opt out of government health insurance programs (particularly in Alberta and Quebec) have sparked public and political debate. Both individual and government efforts to provide assistance to those in need are generally valued and admired by Canadians. Some feel that good citizenship and good government carry an obligation to provide at least some unremunerated services. However, lack of public and political discussion on the issue of unremunerated health services suggests that there is no widely held social expectation to provide hospital or physician services to non-medicare-insured persons. Given the scarcity of resources available to the Canadian health insurance program, and recent discord among Canadians about what set of health care services should be provided to those within public insurance programs, one could reasonably question the justification for providing any public health care services to those ineligible for Canadian public health insurance, even responding to emergency health needs of those not covered (although I do not make this argument here). Distributive justice There is no agreement in the scholarly literature or in widespread practice about what principles should guide in
distributing scarce health care resources or which take precedence if more than one principle seems to apply, but being guided by seemingly applicable principles yields incompatible courses of action. Principles of liberty, utility, need, benefit, merit, equality, efficiency, responsibility, ability to pay, fidelity to patient, restitution, first come first served and other procedural principles of justice are used in different situations.15-18 Often, health care professionals consider several of these principles. For example, a physician might consider primarily need and efficiency in determining how to allocate time with patients when rounds must be cut short. Similarly, there is no agreement about how much we should favour producing the best outcomes with limited resources, how much priority should be given to treating the sickest or most disabled people, when modest benefits to a large number of people should outweigh more significant benefits to fewer people, or when we should rely on a fair democratic process to determine what constitutes a fair rationing outcome.19 Decisions about allocation of resources occur at different levels (macro=government, meso=institution, micro=individual). Different responsibilities, and hence different values/principles, may apply or be weighted differently at different levels. For instance, the needs of populations mandated to serve properly have more weight when setting government and institution policy about allocating and rationing resources (e.g., how much resources to put towards cancer care, radiology services, and other treatments), whereas greater emphasis can be given to the needs of particular individuals when allocating or rationing between individuals (e.g., prioritizing who is seen by the Emergency Department physician, who receives dialysis and so on). Given the scarcity of resources available to Canadian hospitals, a hospital is justified in using distributive justice in allocating resources to people who have, or are eligible for, medicare coverage. Relevant criteria should be developed to guide distribution of limited resources, where possible. Yet, some flexibility among criteria is warranted, as some principles or prioritizations may be deemed more relevant (justified) in some situations over others. For example, inability to pay (for non-emergency treatment) should have great sway in denying health services when the foreseen costs to the hospital (or physicians) is so great as to bring harm to others who have a greater claim to those resources. Yet, inability to pay may be less applicable when foreseen costs to the hospital are low while other principles are compelling. For example, a tourist is injured when she tries to help a mugging victim near the hospital. A health service executive deems that compassion, restitution and benefit justify providing services that will have only minimal effect on hospital resources. A hospital should establish a governing process that demonstrates accountability, when the identification and weighing of relevant principles of justice yield uncertainty or the application of other hospital policies does not solve rationing questions. This process should be ongoing so that Healthcare Management FORUM Gestion des soins de santé – Fall/Automne 2006
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efficacy and effectiveness are maximized and relative consistency is achieved in decisions made. The process should include four elements: transparency of decisions and their rationales, rationales that give a reasonable explanation of how the decisions fulfill social or organizational objectives within resource constraints, a mechanism to appeal decisions or policy, and regulation of the process to ensure these conditions are achieved.20 Persons involved in the establishment of a decision-making accountability process should include the Chief Medical Director (Director of Professional Services), the Chief Financial Officer, representatives of health care professionals who are confronted with choices about whether and how to respond to requests for unremunerated services, and one or more persons who can represent the perspective of people seeking unremunerated services. Jurisdiction considerations It can be expected that provincial governments will resist compensating unremunerated health care as responsibility for the health care of non-citizens (or non-medicare-eligible persons) lies beyond its jurisdiction. From a practical point of view, it is reasonable to predict that a government willing to regularly provide health care services to people who cannot pay for those services will quickly be flooded with large numbers of non-paying and non-medicare-eligible people seeking health care services. This would quickly overwhelm and bankrupt the system to the ire and detriment of Canadians. While setting up special government funds to assist those not eligible for medicare to pay for health services is not a promising alternative, special interest groups may choose to develop charitable funds with access criteria to be used on either an ad-hoc or regular basis for health care services that would otherwise be unremunerated. Discussion In light of these considerations, let us return to the cases presented earlier. In Case 1, Joanna is an international student diagnosed with active TB. Her condition poses a public health emergency, which led to her admission to hospital for a six-week course of treatment. Were options other than “treat free of charge” or “not treat” considered? For instance, is it possible for Joanna to register for university courses late in order to reactivate her health insurance? Can a flexible payment schedule be arranged, perhaps at a reduced rate that waives fixed costs such as overhead? Would the risk to public health be avoided if Joanna wore a mask that filters the TB virus, and returned to her home country (where she hopefully receives treatment)? Decision-makers should compile as complete a list of potential courses of action as possible, before assessing the merits of each option and making a choice. For health care professionals, this means weighing options that usually are not considered, so other interested parties should be involved to help identify and assess possible courses of action. If sending Joanna out of the country is
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not a viable or justified option, and alternative funding is unavailable for her, the hospital may have no choice but to absorb the cost of her care to protect the public (if not Joanna herself) from the morbidity and mortality of TB. Joanna’s situation is complicated by the details of her health insurance policy. Her insurance is void if she is not registered for classes as a full-time student. (Her immigration status may be similarly jeopardized.) A university that admits an international student and the immigration department that issues a student visa bear some responsibility for reasonable oversight such that the student does not place an undue financial or health burden on the Canadian public. Accordingly, there should be minimum standards for health insurance policies (that include hospital care), and oversight of compliance with health insurance criteria (including registration for classes if health insurance hinges on it). Acting in good faith, some people purchase travel health insurance policies assuming that hospital services are covered by these policies. Hospitals can learn too late, that is, after a patient is discharged and the insurance company rejects the bill, that the insurance does not cover services received. Unless the hospital can contact these former patients and receive payment, the expenses must be written off. If this is a recurring problem, a hospital may benefit from a change in process to assess insurance policy coverage prior to treatment commencement or earlier in a hospital stay. In Case 2, Deryek presents to the hospital in a medical emergency, having drowned in a friend’s pool. Hospital intervention is clearly required to restore his life. Resuscitation leads to coma and the need for two weeks of interventions to stabilize his condition. Too unstable for transport, Deryek’s condition remains a medical emergency and the hospital is obligated to provide treatment, regardless of his inability to pay. Once stabilized, if alternate sources of funding are not forthcoming, it may be in the hospital’s financial interest to arrange for and pay to transfer Deryek to a facility that meets his needs in the United States. Although Deryek lives in one of the southern states and his family prefers that he be flown back to his home state, the hospital is obligated only to transfer him to a facility that meets his basic health needs. Since there is a hospital that accepts Deryek’s health insurance in a border state only three hours drive from the Canadian hospital where Deryek lies in a coma, health service executives meet their obligation to Deryek by arranging safe transfer to that location. In Case 3, Leah arrives in the Emergency Department where an irregular heart rate is discovered. It is not clear whether her initial condition should be classified as “emergency” or “urgent.” Sometimes tests and an assessment of response to initial interventions are needed before classifying a condition is possible. Sending Leah from the hospital without assessing her cardiac status would be inappropriate as it could violate the obligation to treat medical emergencies. If she were assessed to have an urgent (not emergency) condition, sending her away without treatment also seems
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problematic, because untreated urgent conditions can often escalate into emergency conditions, which in her case may be more difficult to treat successfully. Furthermore, some stabilizing treatment is available without unduly jeopardizing the health care resources available to others. Thus a favourable ratio of potential benefits to potential harms exists that takes into account not only Leah but also others who have a stronger claim to hospital resources. Leah’s case exemplifies a range that often exists in standards of care. Even though admission to the Coronary Care Unit for closer monitoring is usual practice at the hospital, cardiologists assess that adopting a lower than usual monitoring plan is still an acceptable practice since her situation is not an emergency. Perhaps she will be monitored as an out-patient (this may be acceptable if it does not stress hospital resources or the needs of other patients), or perhaps she will be given instructions to monitor her own condition. One factor of Leah’s case that is troubling is her rejection of medical advice to return to her home country where treatment is available. She rejects this advice even though heart specialists predict that she will need heart surgery in the near future. Is Leah not willing to take responsibility for her own health needs? Does she intend to abuse the generosity of Canadians by having emergency heart surgery if it comes to that? Does a principle of justice based on merit apply and reduce the hospital’s responsibility to act should she return in need of urgent or emergency heart treatment? As with any refusal of medical recommendations, Leah’s comments about not returning home for treatment should be explored. Perhaps she feels it is not safe to return home. Perhaps there are pressing issues involving her family in Canada that she believes take priority. A social services consult may be of assistance. Is there a social responsibility to provide a medical report to the Department of Immigration, which provided the visitor’s visa? Although hospitals are not usually involved in immigration issues, most seekers of unremunerated services are in the country at the discretion of immigration officials and can legitimately be deported (following due process) if they pose a threat to Canadians in terms of security or use of public resources. Health care professionals would need to assess whether there is a duty to protect confidentiality in this case. If a breach of confidentiality is necessary to avoid imminent harm, to identifiable others, which cannot be avoided by other means, and the harm avoided is greater than the harm caused by breaching confidentiality, then the breach is justified. If a breach is justified in Leah’s case, Leah should be informed of the intent to inform immigration and why. This step respects her dignity and might prompt a response from Leah to resolve the risk to others. Rationing decisions are rarely fully satisfying. For “rationing,” by definition, means that there are not enough resources available for all. People who need or could benefit from resources must do without. These are difficult decisions even when all potential recipients of the resources are undisputedly eligible to receive them. Making rationing decisions
that turn on “non-medical” factors (e.g., merit, costs or social consequences) may require basing decisions on at least some criteria that the decision-maker(s) does not have the expertise to assess. Given the values of Canadian health care professionals, and the inherent uncertainties of medicine and assessments of risk, it is reasonable to assume that, where responsible use of resources allow, requests for unremunerated services should be assessed case by case, taking into account individual needs, potential harm to others, compassion and resource availability. Proposed guidelines Based on the above analysis, the following guidelines may assist health care professionals or health service executives to respond to requests for unremunerated health care services. Emergency situations – In an emergency, care needed to sustain the life or integrity of the person must be provided. Urgent, routine or preventative services – There is no legal obligation to provide urgent, routine or preventative care. However, where responsible use of resources allow, requests for unremunerated services should be assessed compassionately, rather than being automatically rejected, as the situation and context of the person may justify providing some measure of health care delivery. Institutional guidance – Institutional policy should be established to assist health care professionals to respond responsibly in situations of providing or refusing unremunerated care. The policy should include identifying principles of justice (rationing) that will have priority in certain types of situations and a process to follow in all other cases, or when extenuating circumstances may apply. Given the complexity of the issues, an multidisciplinary approach may be needed. Accountability process – A process should be established that demonstrates accountability in decisions and practices about providing unremunerated services. The process should include transparency of decisions and rationales that explain how the decisions fulfill social or organizational objectives within resource constraints, a mechanism to appeal decision or policy, and regulation process. Identification of alternative sources for care and financial assistance – Accessible sources of health care delivery and/or funding may be difficult for people to identify or obtain. If possible and practical, people requesting unremunerated services should be directed to alternative sources such as: return to country of citizenship for health care taking into consideration the means to return safely and availability of care; community-based services; aid organizations; insurance plans where health care expenses are covered and the person repays the debt to the insurer.
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Standard of care in exceptional cases – In providing health care services, health care professionals have a professional obligation to provide competent care in conformity with professional standards of care. While no negligent care should be provided, it is important to acknowledge a range of accepted standards of care. It is acceptable to provide unremunerated health care services that are less than what would typically be provided to Canadian citizens, as long as the service is within accepted professional standards of care. Flexible payment options – Many hospitals provide flexible payment schedules on a case-by-case basis when unremunerated services are provided or negotiated. This practice should be continued.21 Where providing services is deemed justified bills may be adjusted to forgive or write off fixed costs but require payment for other costs. Respect for dignity – The dignity of persons requesting or receiving unremunerated care should be respected. Even when services are denied, all communication of decisions, rationales and suggested alternatives should be respectful. Partnership with local and government institutions – Local hospitals should work in partnership with government institutions to help resolve practice uncertainties and inconsistencies of unremunerated services,22 and to solve some of the impediments to accessing health care services (e.g., to require international students to have health insurance that covers hospital services).
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Acknowledgments The analysis and guidelines proposed in this article benefited from discussions with, and feedback from, Jane Chambers-Evans and members of the Clinical Ethics Committee at the Sir Mortimer B. Davis Jewish General Hospital. The author is grateful to Jessica Merkel-Keller for research assistance and the Social Sciences and Humanities Research Council of Canada for financial support of this research.
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