Study: Nurses face ‘moral distress’ when patients lack insurance

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Capital News Service

LANSING – Nurses are caught in the middle between their professional ethics code and constraints on treating patients who can’t afford medical care, a new study says.

As a result, nurses in such situations may experience “moral distress” that “places the profession of nursing in a position of moral compromise and threatens to corrupt the institution of nursing,” according to researchers at Michigan State University and the University of British Columbia.

The team interviewed 20 Michigan nurses with an average of 10 years of practice. Almost all reported caring for patients who at some point had not received medical care due to cost. 

A 2020 national survey found that high costs were the reason why one in 11 adults delayed medical care or went without recommended treatment. And a 2019 Kaiser Family Foundation report said 29% of adults, including ones with cancer and diabetes, chose not to take prescribed medicines because of the cost. 

Moral distress occurs when someone knows the correct thing to do but institutional constraints make it nearly impossible to do that right thing.

The new MSU-British Columbia study said moral conflict arises because the American Nurses Association Code of Ethics requires nurses to provide medical services “according to need.” That means “giving care without regard to personal attributes of the patient, including economic or social circumstances,” it said.

However, there are two aspects to the American health care system that may come into conflict, according to the study in the journal “Nursing Ethics.” 

It said the system treats health care “in part as a public good” but at the same time regards health care as a “market-traded commodity” where access “is governed by the ability to pay.”

The nurses who were interviewed discussed how they see the health care system as broken, meaning it doesn’t function to provide optimum benefits to patients.

“There is an escalating war between (health care) providers and insurance companies,” said MSU nursing professor Douglas Olsen, a coauthor of the study. 

Patients without insurance or who aren’t enrolled in government programs such as Medicaid or Medicare may be billed for their care, often at a much higher price tag than what insurers negotiate with health care providers.

“The cost of health care is unfeasible unless you are extremely wealthy,” Olsen said.

Kim Bogan, an emergency department nurse at Lansing’s Sparrow Hospital, said, “I’ve seen this happen many, many times when people come in with no insurance.”

“They come in and try to pick and choose what services they want,” said Bogan, who has 17 years’ experience in nursing after working as an insurance analyst. She was not interviewed for the study.

As examples, she said uninsured patients may opt for X-rays but can’t afford blood work and mental health patients may break pills in half although the lower amount isn’t helping them.

In other cases, a woman with breast cancer ends up needing a mastectomy rather than a less intrusive lumpectomy because she couldn’t afford a preventive mammogram.

“You have all this medical knowledge and know certain things shouldn’t be compromised,” Bogan said. “It feels like you’re not doing right by letting this factor, money, come into play.”

Olsen said there are instances when nurses and physicians “bend the truth” to secure care for their patients, including how they code a procedure or diagnosis.

Olsen added: “Is it ethical to lie to an individual (insurance) company to get an individual better care?”

The nurses interviewed for the study described situations where diabetic patients couldn’t afford insulin, where cardiac patients couldn’t afford medicines and procedures such as heart catheterizations, where patients who couldn’t afford dental care ended up getting all their teeth pulled and where patients couldn’t afford transportation to doctors’ appointments and pharmacies.

Such situations impose a psychological burden on nurses, the study said, making them feel helpless.

For example, one nurse told the researchers, “I’m frustrated with these big drug companies that can make these decisions (on access to medications) – almost practicing medicine as to who gets what, when they have no idea what’s best for these patients.”

Another said, “I just feel bad they don’t have health care. Is it hard seeing people come in and not get what another patient might have gotten because they could afford care?”

Sparrow Hospital’s Bogan said, “People are all stressed out. It weighs heavy on your heart as a nurse.”

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