Opinion | Ethics Consult: Allow Ineligible Medicaid Recipient to Receive Novel Drug?

Welcome to Ethics Consult — an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma from a true, but anonymized, patient care case. You vote on your decision in the case and, next week, we’ll reveal how you all made the call. Bioethicist Jacob M. Appel, MD, JD, will also weigh in with an ethical framework to help you learn and prepare.

The following case is adapted from Appel’s 2019 book, Who Says You’re Dead? Medical & Ethical Dilemmas for the Curious & Concerned.

Wilbert is a 30-year-old man with a newly diagnosed pancreatic tumor. His wife is 3 months pregnant, and there is the possibility, estimated at 10%, that an extremely expensive new drug will extend his life long enough for him to witness the birth of his first child. He relies on Medicaid for his healthcare coverage and cannot afford private insurance. He is also not eligible for clinical trials.

The leaders of the state in which Wilbert resides have recently passed legislation that prevents its Medicaid program from paying for novel drugs for patients with under a 5% chance of surviving 5 years. The funds saved have been earmarked for preventive medicine, expanding such coverage to 100,000 working-class children. Economists estimate this approach will save hundreds of lives every year.

In agreeing to the law, the governor required the state legislature to establish an emergency review board — a commission of physicians and other healthcare workers that can override these rules and provide funding for such novel drugs under “extraordinary circumstances.” Wilbert petitions the board for an exception, noting, “I know my chances of long-term survival are extremely low, but I have a realistic prospect of living to see my first child born — and that would mean the world to me and my family.”

Jacob M. Appel, MD, JD, is director of ethics education in psychiatry and a member of the institutional review board at the Icahn School of Medicine at Mount Sinai in New York City. He holds an MD from Columbia University, a JD from Harvard Law School, and a bioethics MA from Albany Medical College.

And check out some of our past Ethics Consult cases:

Force Doctors to Remove Bullet From Robbery Suspect’s Leg?

Forcibly Medicate Psychiatric Patient?

Approve a Horn Implantation in Patient’s Skull?