D404 Task 1 Ethical Dilemma Analysis Example

One Opening, Two Families: An Ethical Analysis of How an Interdisciplinary Committee Should Allocate the Last Subsidized Place in an Adult Day Program

Student Name

Leavitt School of Health, Western Governors University

D404: Healthcare Values and Ethics, Task 1

Course Instructor

Month Day, Year

One Opening, Two Families: An Ethical Analysis of How an Interdisciplinary Committee Should Allocate the Last Subsidized Place in an Adult Day Program

The Case

Cedar Commons is a composite nonprofit adult day health program that serves older adults with dementia and other chronic conditions. Most participants pay through a state Medicaid waiver or privately, but the program also funds a small number of subsidized places from a county grant for people who earn too little to pay and do not yet qualify for Medicaid. One subsidized place has opened. Two applicants meet the grant's eligibility rules, and the admissions committee must choose between them. The committee includes the program director, a registered nurse, a social worker, the activities coordinator and the finance manager.

Eleanor Pike is 81, has moderate Alzheimer's disease and lives alone in an apartment. Her only daughter lives two hours away and calls every evening. In the past month, a neighbor found Mrs. Pike outside at night twice, and the nurse's home assessment found missed medications and an empty refrigerator. Walter Grayson is 76, also has moderate Alzheimer's disease and lives with his wife Ruth, who is 74. He becomes agitated each evening and sleeps poorly, and so does she. Mrs. Grayson has been to the emergency department twice this year with chest pain that was attributed to stress, and she told the social worker, "I can't keep doing this. If nothing changes, he'll have to go to a nursing home." Both families have been on the waitlist for about the same time.

The Ethical Dilemma

The dilemma is not whether to help, but whom. The committee has an obligation to Mrs. Pike, whose safety is at risk every night she is alone and confused, and an obligation to Mr. Grayson, whose place at home, and his wife's health, depend on relief that neither can buy. Both obligations are real, the program has one place, and honoring one means leaving the other unmet for now. A second, quieter dilemma sits inside the first: how much private information the committee needs in order to decide, and how that information should be handled.

Ethical Principles in Conflict

Health care decisions are commonly guided by four principles described by Beauchamp and Childress (2019): respect for autonomy, nonmaleficence, beneficence and justice. In this case, justice and beneficence do most of the work, and they can be argued in both directions.

Beneficence asks which choice does the most good. For Mrs. Pike, a day program would provide supervision, a meal, medication support and daily contact, and it would give staff a chance to see decline early. But it would not solve her greatest risk, which occurs at night when the program is closed. For Mr. Grayson, the benefit is shared. In a study of 121 family caregivers, stress exposure and stress appraisals fell significantly on days the relative attended adult day services, and people with dementia showed fewer evening behavior problems and slept better after attending (Zarit et al., 2011). A place for Mr. Grayson could therefore help two people at once.

Justice asks how a scarce resource should be distributed fairly. Persad et al. (2009) argue that no single principle, such as sickest first or first come, first served, is adequate on its own, and that allocation systems should combine several principles, including priority to the worst off and the prospect of benefit. Mrs. Pike may be the worse off today in terms of immediate safety. Mr. Grayson may offer the greater prospect of benefit, because the service matches his need closely and may prevent a move to a nursing home. Caregiver stress and a caregiver's sense of being trapped are among the most consistent predictors of nursing home admission for people with dementia (Gaugler et al., 2009), and Mrs. Grayson has said almost exactly that.

Respect for autonomy also applies. Both applicants have moderate dementia, so their families and legal representatives speak for them, but each has expressed a wish to stay at home. Nonmaleficence reminds the committee that delay itself causes harm: whoever is not chosen will face another period of risk, and the plan must reduce that harm rather than ignore it.

Legal, Regulatory and Privacy Issues

Because Cedar Commons bills Medicaid for services, it is a covered entity under HIPAA, and the applicants' assessment records are protected health information. The minimum necessary standard requires the program to limit the use and disclosure of that information to what is reasonably needed for the purpose (U.S. Department of Health and Human Services [HHS], n.d.). The committee needs each applicant's functional status, safety risks, caregiver situation and eligibility. It does not need full medical histories, psychiatric notes or financial details beyond eligibility, and the finance manager and activities coordinator need less than the nurse and social worker.

A problem has already occurred. Before the meeting, the social worker described both families, by name, in the staff group text used for scheduling. The message included Mrs. Grayson's emergency visits. Mrs. Grayson is not a client of the program, and she shared that information in confidence to explain her strain. The director should move the discussion to the secure record, have the message deleted, remind staff that client information does not belong in general group messages and follow the program's policy for reviewing a possible privacy incident.

The grant also has rules. The county requires that subsidized places go to eligible residents through a documented process, and federal civil rights law prohibits discrimination on the basis of race, national origin, disability, sex or age in programs that receive federal funding. During the meeting, the finance manager suggested choosing the applicant more likely to become a paying Medicaid participant later. That consideration is not relevant to a subsidy meant for people who cannot pay, and a decision based on it would be hard to defend to the county or to the families.

Stakeholder Perspectives

The nurse favors Mrs. Pike because of the nighttime wandering and missed medications, which she sees as immediate medical danger. The social worker favors Mr. Grayson because of his wife's health and the risk that the household will collapse. The activities coordinator notes that Mr. Grayson's evening agitation may improve with structured daytime activity, while Mrs. Pike is socially isolated and would benefit from company. The director is concerned about fairness and about how the decision will look to the family not chosen. Mrs. Pike's daughter and Mrs. Grayson each believe, understandably, that their family's need is greater. Each view reflects a real value, which is why the way the committee decides deserves as much care as the decision.

Recommended Resolution

The committee should not decide by whoever argues most strongly. It should adopt written criteria for subsidized places and apply them to both applicants. Reasonable criteria include the risk of nursing home placement within 90 days, safety risk that the program can actually reduce, caregiver strain measured with a standard tool, and time on the waitlist as a tiebreaker. Each member should score both applicants from the same minimum necessary summary, the scores should be recorded, and the family not chosen should be told the reasons and how to appeal.

Applied to this case, the criteria favor Mr. Grayson. His risk of placement is high and specific, the program's hours match his need, and the benefit extends to his wife. Mrs. Pike's most serious risk occurs at night, which a day program cannot address. The committee should therefore offer the place to Mr. Grayson and, on the same day, act on Mrs. Pike's risks: the social worker should make a same-day referral to the area agency on aging covering her address, asking about in-home services and a medication dispenser, discuss a door alarm and a nighttime check-in with her daughter, begin a Medicaid eligibility review and place her first for the next opening. This does not remove the loss to Mrs. Pike, but it reduces the harm of waiting and shows that the decision rested on the fit between need and service rather than on sympathy.

Personal Values and Reflection

My first reaction was to choose Mrs. Pike, because an older woman alone at night is a frightening picture. Working through the case showed me that my instinct favored the most visible danger, not necessarily the choice that would do the most good. I also value loyalty to clients who have waited, which could lead me to favor whoever applied first. In practice, I would protect against both instincts the way this paper recommends: by agreeing on criteria before looking at names, by keeping private information within the smallest circle that needs it and by saying out loud, in the meeting, what we are giving up.

References

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Gaugler, J. E., Yu, F., Krichbaum, K., & Wyman, J. F. (2009). Predictors of nursing home admission for persons with dementia. Medical Care, 47(2), 191-198. https://doi.org/10.1097/MLR.0b013e31818457ce

Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. The Lancet, 373(9661), 423-431. https://doi.org/10.1016/S0140-6736(09)60137-9

U.S. Department of Health and Human Services. (n.d.). Minimum necessary requirement. Retrieved September 29, 2026, from https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/minimum-necessary-requirement/index.html

Zarit, S. H., Kim, K., Femia, E. E., Almeida, D. M., Savla, J., & Molenaar, P. C. M. (2011). Effects of adult day care on daily stress of caregivers: A within-person approach. The Journals of Gerontology: Series B, 66B(5), 538-546. https://doi.org/10.1093/geronb/gbr030