How to Manage a Teenaged Patient Seeking Medically Unnecessary Rhinoplasty

Indeed, even if beneficence is the guidepost for the physician’s willingness to submit false information to the insurance company, he or she is compromising professional honesty and reputation. Should an outside audit be conducted, the financial penalty for falsifying records would be the least important liability—loss of integrity is far worse, and will surely result in this young woman viewing the physician in an entirely different (and unflattering) light. Large professional ethical compromises are not necessary to jeopardize a physician’s integrity—many small violations and repeated unethical decisions can do just as much damage.

Ethical Considerations

So, what are some ethically acceptable considerations that will help this patient, while not compromising her autonomy?

1. Explain that she does not meet the criteria for insurance coverage of a limited rhinoplasty to improve the nasal hump deformity. The patient and father are owed the truth.
2. Explain, in full, the out-of-pocket, self-pay costs of a rhinoplasty, so that the family may make an informed decision that includes the financial burden of the procedure.
3. Discuss a payment schedule or discounted surgical fees that would not burden the family at a time when they also want to secure a good higher education for their daughter. Discuss in detail any possibility of the family “borrowing money” to pay for the surgery in light of the financial burden and risk of a loan. Easily accessed loans can also bias the patient toward surgery.
4. Consider a “pro bono” approach to your fees, although this may violate the principle of justice if it is not applied across the spectrum of the physician’s patient load.
5. Introduce the idea that the patient may elect to postpone the surgery until the patient’s/family’s financial situation is improved, possibly delaying the surgery until the patient is of majority age.

Regardless of the ethically responsible options presented to the patient, the physician must give the patient and family time to think through and discuss what would be best for her. She is still a teenager, and additional maturation might provide a somewhat different perspective for her. For the physician, it is not worth compromising your integrity by falsifying medical information to an insurance company, even when this action is considered to be for “a good cause.”