Patient’s Request Presents Ethical Dilemma

Krystal Chee, OD

A 57-year-old Caucasian female presented to a community clinic for an eye exam with the chief complaint of being “unable to see anything.” This patient was being followed by an outside ophthalmologist, whose previous records revealed a history of dense panretinal photocoagulation (PRP) for proliferative diabetic retinopathy OU, a macular hole OD and macular scarring OS. Her medical history was significant for diabetes mellitus type 2 and hypertension.

On observation of the patient walking from the waiting area to the exam room, she displayed difficulty ambulating down hallways and expressed trouble distinguishing clinicians. During the exam, her visual acuities (VAs) were counting fingers at 40 cm OD and 20/50 OS. VAs did not improve with pinhole or manifest refraction. A threshold visual field was performed, and it revealed constricted visual fields OU. The right eye’s widest visual field was 15 degrees; the left eye’s visual field was constricted superiorly and inferiorly, but subtended a full 54 degrees horizontally. Dilated ocular health exam confirmed the patient’s history of PRP, macular hole OD and macular scarring OS. We informed the patient that a spectacle correction would not improve her vision and advised her to schedule an appointment to be seen in our low vision clinic. The patient then requested a diagnosis of legal blindness and stated that she had received benefits through being legally blind in the past. She provided physical documentation of this diagnosis in the form of a letter from her ophthalmologist, which stated she was legally blind. However, it was clear she did not qualify as legally blind per the U.S. Social Security Administration’s definition.

Low Vision vs. Legal Blindness

As optometrists, we encounter situations in which we need to appropriately draw the line between patients with low vision and patients who can be defined as legally blind. The law defines legal blindness for public safety reasons (driving) as well as for determining eligibility for disability benefits funded by the government. Legal blindness is defined by the U.S. Social Security Administration (SSA) as best-corrected visual acuity of 20/200 or worse in the better eye, or visual field of 20 degrees or less in the better eye.¹ In addition to monetary assistance, government-funded programs for people with legal blindness can provide other services and resources.¹ The Americans with Disabilities Act calls for reasonable accommodations by employers to allow for equal employment opportunity, such as closed-circuit televisions, screen magnifiers, etc.² While these benefits are of great assistance to legally blind patients, factors other than visual acuity and visual field affect a patient’s visual functionality, e.g., contrast sensitivity. While a patient may not qualify as legally blind under the U.S. SSA’s guidelines, use of his or her low vision can still be very challenging if one or more of these additional hindrances are present.

As stated in the American Optometric Association (AOA) Code of Ethics, one of an optometrist’s duties is “to advance professional knowledge and proficiency to maintain and expand competence to benefit our patients.”³ Part of our job as optometrists is to ensure that legally blind and low vision patients are properly diagnosed and directed to the appropriate resources and services that can help them to achieve the highest quality of life possible. According to An Optometrist’s Guide to Clinical Ethics, “Optometrists must serve as patient advocates and help their patients receive the best available care.”⁴ This means we must be up-to-date with SSA requirements and how to direct patients towards receiving disability benefits. While we are to be advocates for the well-being of our patients, we must also recognize that these benefits are not to be abused. We also have an “obligation to protect the health and welfare of society,”³ including appropriate allocation of resources to those who are in serious need.

Patients may want to be classified as legally blind, as the patient in this case wanted, especially if they have been granted related benefits in the past. While one of our ethical principles is to help others (beneficence), it is necessary to be truthful regarding our exam findings in order to uphold our ethical standards. Additionally, we should consider rehabilitation for these patients by way of low vision services and aides. If we do not have the means to provide these services ourselves, we must follow the Code of Ethics, which states our responsibility to “advise our patients whenever consultation with, or referral to another optometrist or other health professional is appropriate.”³ This goes along with being an advocate for our low vision patients, especially those who feel overwhelmed or helpless in their daily functioning because of their reduced vision. The SSA states that even if a patient is not “legally blind” per their definition, a visual impairment may still make him or her eligible for Social Security benefits on the basis of disability.¹ For these cases, directing our patients to a Social Security disability attorney or advocate may be the best option to help them benefit from necessary services.

Patient Education and Management

Considering that this patient’s visual acuity and the extent of visual field were both better than the definition of legal blindness per the U.S. SSA, we determined we could not diagnose her with legal blindness despite her previous documentation and receipt of benefits. We consulted thoroughly with her and advised her of all of her options for low vision rehabilitation. Another aspect of optometric ethics is to strive to ensure that all patients have access to eye and vision care³ regardless of transportation or financial limitations. We connected this patient to the local Department of Rehabilitation, which would be able to help her set up services through our low vision clinic. We also advised her that despite not qualifying as legally blind, her visual impairment could still allow her to gain services through the SSA and that an advocate could help her determine the appropriate options. After discussing at length the potential benefits of low vision services to improve her employment opportunities and quality of life, our patient was thankful for our advocacy and was optimistic about maximizing the functionality of her vision.

References

1. If You’re Blind Or Have Low Vision – How We Can Help [Internet]. Baltimore, MD: The United States Social Security Administration; [cited 2016 June 23]. Available from: https://www.ssa.gov/pubs/EN-05-10052.pdf.
2. Questions & Answers about Blindness and Vision Impairments in the Workplace and the Americans with Disabilities Act (ADA) [Internet]. Washington, DC: U.S. Equal Employment Opportunity Commission; [cited 2016 June 23]. Available from: https://www.eeoc.gov/eeoc/publications/qa_vision.cfm#_edn3.
3. Code of Ethics [Internet]. St. Louis, MO: American Optometric Association; c2016 [cited 2016 June 23]. Available from: https://www.aoa.org/about-the-aoa/ethics-and-values/code-of-ethics?sso=y.
4. An Optometrist’s Guide to Clinical Ethics [Internet]. Eds. Norman BR and Heitman E. St. Louis, MO: American Optometric Association; c2000 [cited 2016 June 23]. Available from: https://www.aoa.org/documents/optometrists/book.pdf.

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