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Is Discounted Therapy Fair?

by David Shipley

A friend of mine is a therapist. She faced the following dilemma.

My friend specialises in enhancing fertility and was approached by a prospective patient who wished to become pregnant but could not afford to pay the standard fee of £45 per treatment as she was on benefits. The woman was aged 40 and had no children. What should my friend the therapist have done?

The options facing her are: offer the treatment at a reduced rate, refuse to treat the prospective patient, or explain that the rate is fixed and leave it to the woman to decide whether she can find a way to cover the cost of the treatment.

Given the age of the prospective patient, if treatment is given it may be expensive and have little chance of success, but if it is withheld or unaffordable the woman may lose her last chance of having a child.

Offering the treatment at a reduced rate has the superficial appeal of appearing sympathetic to the prospective patient, bearing in mind the unhappiness that many people experience as a result of infertility, but provokes some knotty questions:

1) Does this establish a precedent for a means-tested approach to payment? If so, this would rapidly become impractical as the therapist ought to demand full information concerning prospective patients’ income, outgo, assets and liabilities to ensure that a fair decision is made. If not, why not? Is it reasonable to make an individual special case without reviewing each other patient’s financial circumstances?

2) If the woman is unable to afford the modest cost of a course of treatment, roughly the cost of a mid-range pram, how will she be able to afford to bring up the child?

3) Does the therapist have a responsibility to society as a whole or to the unborn (indeed, unconceived) child to take a position on the woman’s ability to provide for her child, or does she simply view the infertility as a condition to be treated regardless of the outcome? Is it appropriate for her to take into account considerations of the child’s life chances if born into poverty?

One could argue that if the therapist considers that the birth of a child in such circumstances is not in the interests of society as a whole, then perhaps she should simply refuse to treat the prospective patient at all. Although some might say that the therapist has delusions of grandeur and does not have the right to sit in judgment on the patient’s suitability for parenthood, a decision is being made either consciously or inadvertently so the therapist should bear in mind the likely consequences of her course of action,

While insisting on the full rate may appear rapacious and unsympathetic, it has the benefits of maintaining an equitable approach to all patients and avoiding inadvertent intervention in the matter of whether the woman should be considering parenthood. On the other hand it may simply be dodging responsibility for the decision.

(Please assume for the purposes of any ethical debate that the therapy has beneficial effects but the outcome is by no means guaranteed; it would be a distraction to get into a debate about the relative effectiveness of different therapies, or the scope and limitation of randomised controlled trials. However, regardless of the effectiveness of the therapy, the patient’s chances of delivering a healthy baby decrease rapidly after the age of 40, so if treatment is refused or delayed this reduces her chances of conceiving)

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7 Comment on this post

  1. David, Is your friend working in a private capacity or for the NHS? (I’m assuming this is taking place in the UK.) To me this makes a crucial difference.

    More generally, I have the following comments on this.

    1. “…the therapist should bear in mind the likely consequences of her course of action.” This implies a consequentialist view of morality. It is one that I share, but I think it’s important to point this out nevertheless.

    2. Even from a consequentialist, and more specifically utilitarian perspective, we should not endeavour always to take account of all possible consequences of all our actions. It is essential to have rules, which in general we respect (i.e. unless there seem to be overriding reasons not to do so), and which we review from time to time (from some kind of cost-benefit perspective).

    It is with regard to this “rule utilitarian” perspective that I think it’s important to know in what professional context your friend is working: it determines the kind of rules that currently apply. Once we know that, we can see how those rules (to the extent that they are clear) would apply to this specific case, and also debate whether they are ethically sound (from whichever meta-ethical standpoint we happen to take).

  2. Let us imagine that instead of concerning a fertility therapist, the post is about a plastic surgeon who is asked for free treatment, or a doctor whose patient asks for free Viagra – both demands provoked by the extreme unhappiness of the patient.
    I choose these cases as they are both examples of what we might call « complementary medicine », that is, overcoming conditions that are neither life-threatening nor usually judged as handicapping a normal life. And both usually require, like fertility treatment, payment.

    Would the same knotty questions arise ? If not, why not ?

  3. Peter
    She is working privately. It is fair to say that any decision she might take would be constrained by rules and guidelines, far more so within the NHS than otherwise, but as a private practitioner she is free to charge whatever she likes and to accept or refuse a patient. You are right that in this instance I am taking a consequentialist view of morality; I agree that it is essential to have rules, but only because the consequence of not having rules is that one becomes rudderless and vulnerable, and not per se. I am not convinced that rules come into play in this instance, rather than a general utilitarian principle, as I do not have the imagination to think of a relevant rule that one could justify following regardless of the outcome.
    I agree that we should not endeavour always to take account of all possible consequences, but I do think we should examine the chain of cause and effect to identify likely and material consequences, otherwise we move into the world that career politicians seem to inhabit, where actions and their consequences are somehow disconnected, and intent is all regardless of how easy it is to anticipate the unintended consequences.

    I would say yes, the same questions would arise. The plastic surgeon might end up taking a subjective view as to the patient’s degree of need, and the urologist…well let’s not go there.

  4. Thanks for your reply, David.
    All three cases are thus seemingly reduced to how a supplier decides whether or not to give preferential terms to a potential customer.
    Shouldn’t your friend simply forget her anguish ?
    Is her situation so much different from that of any other (non-medical) supplier faced with a customer’s hard-luck story ?

    Perhaps one could argue that medicine and other therapies are special cases. However, I’m not sure what arguments would be used to differentiate these service from others that impinge on human happiness.

    1. We could try focussing on the nature of the service, by stating that they concern human bodies – but so do tattoing and hairdressing and fitness centres.
    2. We could try focussing on the notion of happiness, but music, art, theatre and a host of other paying services seem to exclude this as a criterion for differentiation.
    3. More promisingly, perhaps, we could focus on a human rights argument : that each person has a right to procreation, a fulfilled sex-life and freedom from the fear of ridicule of their physical attributes.
    I fear however that this would push out the notion of human rights too far, and thus unfortunately decredibilise it.
    In addition, if this argument could succeed, why, in a society with a free health service, are these treatments charged for ?

  5. How important is it that the person who must decide is the supplier — the service provider. What if the person who must decide is not the supplier but a family member who is asked to contribute? What if, as is often the case in the US, a private charity is set up for the particular person and contributions are sought through local news stations and posters pinned up on lamp posts and telephone poles? In all these cases, the patient comes out with lower than usual costs for the service.

    Could the service provider charge the standard fee and then have the office contribute an amount of money to the patient to help her get the service? That is, is the ethical question really a question of accounting?

  6. The therapist should perhaps point out evidence demonstrating having children tends to actually reduce happiness.

  7. Both Anthony and Dennis make good points in my view. The “rule” I would envisage applying in this case is indeed the rule (forgive the relative imprecision) that in a private setting one is free to charge whatever one wants so as to maximise one’s profit, provided one is not doing anything obviously unethical (lying, cheating, deceiving…), and trust the market to do the rest. It is exactly as Anthony said: the would-be customer’s story is really no different to any other customer’s hard-luck story.

    More generally, for me the point of rules is not to prevent us becoming “rudderless and vulnerable”, it’s basically a short-cut precisely do that we *don’t* have to work out the consequences each and every time we make a decision in commonly occurring situation. A trivial example is setting one’s alarm clock: I may have a rule that I set the alarm each working day at 7; at some point I will have worked out (in some intuitive way of course) the consequences, decided that 7 is about right, and made it a rule. Having the rule saves me from having to work it out from scratch each evening.

    So in a market situation, the idea is that it’s been worked out (by Adam Smith, with subsequent modifications which remain controversial, but most of us more-or-less believe in the virtue of well-functioning, appropriately regulated markets) that given the right macro conditions (hence the need for regulation to prevent market failures) private operations can aim to maximise their profit in their chosen professional activity and this will more-or-less work out for the common good. There are plenty of caveats one can (and should) put around that, but that’s the basic idea, and it seems to apply to this case as much as to anybody else. The customer’s hard-luck story is not the supplier’s problem, it’s a question of supply and demand, and nobody wastes time trying to second-guess what somebody else’s real interests are. It’s an excellent example of rule utilitarianism at work.

    Regarding career politicians, I do agree that, as with many other walks of life (politicians are no worse than the rest of us imo), they may have a tendency to deliberately or (more often) subconciously blind themselves to obvious consequences so as to be able to do what is in their self-interest while pretending (or even believing) that they are acting for the common good. But the problem is not that they are following rules. The problem is that they are using self-serving, motivated reasoning. In fact it is precisely to compensate for this tendency, which we all have to varying degrees, that we need to have rules. Imagining that people can be persuaded always to work out the consequences of their actions even when it’s not in their interests to do so, and in the heat of (political) battle, is doubly if not triply naïve.

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