Ethics and Wound Care Protection Status
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by Bruce E. Ruben MD

hippocratic_oath.jpg"As to diseases, make a habit of two things – to help, or at least, to do no harm."
– Hippocrates

This particular blog is not necessarily intended to educate, but to be a thinking piece that asks more questions than it answers.

I want to pose a medical ethics question to you. Here's the given: you're an expert in wound care, board certified in infectious disease, internal medicine and undersea and hyperbaric medicine. And, you've been practicing for about 25 years.

Now here's the case: A 46-year-old man has a catastrophic auto accident resulting in paraplegia. A few years later, pressure ulcers develop that cost thousands of dollars in wound care resources just to get them on the road to healing. They have included three rounds of intensive IV antibiotics, numerous wound debridements, expensive skin substitutes and hundreds of dressing changes.

application_denied.jpgSuddenly, your patient's insurance company begins denying benefits to the patient and drastically reduces payments to you. But there is a lot of wound care that still has to happen.

As your patient's physician, what are your responsibilities in this scenario?
Do you continue providing services to your patient regardless of payment?
Do you challenge the insurance company on behalf of your patient?
What's the ethical thing to do?

And what about these faceless, bureaucratic entities called insurance companies? Ethically, how can they deny benefits to a patient at the precise moment when that patient needs the benefits the most? Of course, the answer, predictably, is about the money. Somewhere on the insurance company's actuarial tables, it's just not economically feasible to continue expensive wound care treatments indefinitely. Financially, surely the insurance company would rather pay once for an amputation than continue shelling out funds for treatments open-endedly. After all, healing isn't an exact science and paraplegic patients are prone to suffer recurring pressure sores.

Still, subtly or not so subtly, the insurance company is dictating the medical treatment plan, not the physician. That's disturbing since presumably, insurance company bean counters don't have medical degrees.

But what's lurking behind their actuarial tables is one fact that doesn't bode particularly well for the wound care patient. Statistically, patients who undergo above-the-knee amputations have shorter life expectancies, down to just five years for diabetic and older wound care patients. It comes down to math and ethics – a $50,000 amputation and a closed account in five years, versus the possibility of thousands more dollars indefinitely...with no concrete guarantees.

When Emotions Play Into Medical Ethics

Here's another ethics challenge that we encounter. Sometimes we see this in our wound care center. A mother or a father calls desperately seeking hyperbaric oxygen treatments for a son who has suffered a traumatic brain injury over a year ago. You explain to the parent that the treatments will not be covered by insurance, since the condition is not one of the 14 approved indications for the use of HBOT. And, the treatments will cost many thousands of dollars.

Do you, the physician, succumb to the parent's desperation, prescribe the treatments and bill for services, knowing that the possibilities for improvement are miniscule?

snake_oil.pngAnd if we do succumb, are we no more ethical than the carpetbagger of the late 19th century peddling the magic elixir? Step right up and try this amazing hyperbaric chamber, it'll cure whatever ails you! And this Olestra, it'll melt the fat right off of you!

Ethical Considerations and the Hippocratic Oath

The practice of medicine is full of ethical challenges. Questions surrounding organ donation, abortion, assisted suicide and universal health care are among the first to come to mind. But even the axiom that started this piece by Hippocrates, " do no harm," is burdened with ethical considerations. For example, consider that in the first ethics scenario above, one could argue that by stopping treatment as a result of not being paid by the insurance company, you, the physician, would inadvertently be doing harm to the patient.

In the end, it's incumbent on every physician and health care provider to do the right thing and not cross any lines when it comes to ethics. But having the capability to see those lines in the first place – and there are plenty of them – is certainly one of the biggest challenges in medicine today.

About the Author
Dr. Bruce Ruben is the Founder and Medical Director of Encompass HealthCare, located in West Bloomfield, Michigan. Encompass Healthcare is an outpatient facility featuring advanced wound care, IV antibiotic therapies, hyperbaric oxygen treatment, nutritional assessment, and other treatment modalities. Dr. Ruben is board certified in Internal Medicine, Infectious Disease, and in Undersea and Hyperbaric Medicine. He is a member of the Medical and Scientific Advisory Committee and National Spinal Cord Injury Association (NSCIA) board.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

Wound Dressing Selection for Pressure Ulcers


Thank you, Dr. Ruben for putting into printed words what we, wound nurses have been struggling with for a long time. There are no easy answers but since there is no price to sympathy and compassion, as health care providers we never leave the client, whatever outcomes result from any decision reached.

Dr. Ruben, Thank you for expressing what many of us feel. The insurance company and not the doctor is dictating what type of treatment the patient should be prescribed. These are not medical professionals and they have no clue outside of what they feel they understand. Really the insurance company's are bullies! They know that when they don't get their way, they pull the financial power to sway providers to their side. I know that the answers are not easy but continuing to care by Advocating for our patients, educating family and clients and just doing our best will always lead us down the right road.

I'm going to paraphrase Albert Einstein 'If you keep doing the same thing and expect a different result, this is a form of insanity.' Are we guilty of this in wound care? How many times to we in wound care repeat the same type of treatment and expect a different result? Wound care is about the difficult to heal wound(s). Resources are limited because there is not an infinite amount of money to spend. It's easy to blame someone else for the wound's failure. It's much more difficult to be creative and actively engage the pt. in the wound healing process.
You are very quiet about the pt's nutritional status. You did not mention anything about creative ways to off-load or cushions used for pressure reduction. Does the pt. know sitting in the chair for 12 hrs a day is not conductive to wound healing? Does he say he is repositioned and he is not willing to admit how many hours he sits (or lays)in the same position.
Insurance companies are not broke but Medicare is going broke and Medicaid is broke.
I am obviously in the camp of 'we need to do more with less'.

At Encompass HealthCare, our entire practice is based on resolving the underlying conditions contributing to non-healing wounds so the body can do what it does best: heal wounds.

The example used in the blog was meant to present a very basic scenario in order to expose an ethical dilemma and not to determine what treatment protocols should have been used. (That's a good idea, though, for a future blog post!)

Your comments are very good as they offer a perspective from which we operate in wound care. Thank you for contributing to the whole learning process!


Dr. Ruben

I wish all doctors were as compassionate and caring as you. You make the world a better place!

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