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To the Editor: In the Grand Rounds discussion of a patient's refusal of care, Dr Carrese¹ describes a familiar and difficult case in which respect for patient autonomy conflicts with the principle of beneficence: an older bedbound woman, judged competent to make medical decisions, refuses nursing home care after a hospitalization, yet the medical team is concerned that she cannot receive sufficient care at home to prevent further deterioration.

Carrese presents an ethical framework within which to view this case, but we believe an important perspective is sidelined in his discussion. Optimal care for this patient, allowing her to return home with sufficient nursing care, is prohibited by her financial circumstances. The physicians' responsibilities to promote beneficence and patient autonomy are in conflict only because of the patient's socioeconomic status.

Physicians who care for patients with low socioeconomic status may be faced with reconciling the promotion of high-quality care for . . . [Full Text of this Article]

Susannah M. Bernheim, MD, MHS
susannah.bernheim@yale.edu
Department of Internal Medicine
Yale University School of Medicine
New Haven, Conn

Joseph S. Ross, MD, MHS
Department of Geriatrics and Adult Development
Mount Sinai School of Medicine
New York, NY

Elizabeth H. Bradley, PhD
Department of Epidemiology and Public Health
Yale University School of Medicine
New Haven, Conn

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