Physicians have available to them many treatment choices that are uninsured services. If a treatment is the best available for a condition, regardless of its status, it is the physician's duty to inform the patient of such treatment, including its cost. In fact, physicians do so every day when they discuss the cost of prescription drugs with patients who have no public or private drug insurance. Therefore, many treatment options not included within provincial insurance plans are available and must be offered to patients when appropriate.
Kluge also says that "a physician does not fail in his duty when he does not provide a treatment that is unavailable to him." Unquestionably. But it is completely incorrect to state that simply because a service is uninsured it is therefore unavailable. I trust that this distinction is clear, because it is a critical one, especially as governments move to delist services.
Brian W. Gregory, BSc, MD, FRCPC
Chair
Deinsurance Subcommittee
British Columbia Medical Association
Vancouver, BC
Ethically (and probably also legally) a physician should indeed acquaint a patient with a treatment option that is medically appropriate even if it is not insured. However, in informing the patient of such an option, the physician must also inform the patient that it is not an insured service and that the patient will have to pay for it.
At this juncture Dr. Gregory and I part company. If the patient cannot pay for the uninsured service, then, although the physician may offer the service in some theoretical sense, in reality it is not available unless the physician and other relevant health care providers are willing to waive the bill.
In other words, the difference between what Gregory is saying and what I said is the difference between an option in theory and in reality. An uninsured service that the patient cannot pay for is an unavailable
service in real life. The fact that a richer patient could pay for it does not make it available to a poorer patient. That would be like saying to the 40 to 45 million people in the United States who cannot afford medical insurance and yet are too well off to qualify for Medicaid or Medicare that health care is available to them because all they have to do is pay for it.
Gregory has no real objection to my major point: that if a service is not available in the real sense, then the physician cannot be held responsible for failing to provide it. A lot of physicians are worried about this point, and it is time to put that worry to rest.
Gregory does not mention, but I believe that he and I agree, that deinsuring certain types of services is deplorable.
Eike-Henner W. Kluge, PhD
Member
Advisory Committee on Ethical Issues in Health Care
British Columbia Ministry of Health
Vancouver, BC