Night Shift
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“Of course, health care is a right,” my young friend said with a disdainful twist of her face and a shudder that seemed to shake off the unthinkable. “You are a doctor,” she added, reminding me of what I had done for thirty years. “ Surely you agree that health care is a basic human right.”

“Not really,” I said with a casual shrug. She blinked long as if doing so would allow her to hear me say something different. “Rights are intrinsic to the person. You know, the right to do as I want as long as I don’t hurt someone. But health care, if it is a right, involves requiring someone to do something for me. And by definition, that makes the person rendering the care a slave to the person with the right to that care.”

She shuttered again.

I was riding in the back of a pickup truck through the streets of Port au Prince with a group that was half emergency physicians and half graduate students in development. It made for some very interesting and kinetic discussions, the theoreticians versus the pragmatists. And here we were in the middle of one of the most medically deprived populations in the western hemisphere asking the simple question, ‘How can you really help people in need?’
I brought this group to Haiti on the second anniversary of the earthquake to do a general assessment of the progress since those dark days of January 2010 when almost 300,000 people lost their lives. There was no question that emergency help was needed and had been provided by thousands of volunteers who had poured into Haiti in the aftermath of the quake. But how, we were asking, was the transition going towards a stable, sustainable health care system? In pursuit of this answer, it made perfect sense to mix the disaster specialists with the development students and see what we came up with. Again and again our discussions came back to this basic question, “Is health care a human right?”

“It’s simple social justice,“ my PhD student stated with confidence. “People have the right to access to health care.”

“Let’s take that statement apart, if you don’t mind,” I said, trying my best, unsuccessfully, not to be pedantic. “Justice is required when someone has done something wrong to another person. The ‘scales’, so to speak, are out of balance. If someone takes something from me, they have to give it back, or give me something in return to try to ‘make me whole’. And the justice system is charged with doing that task. If through my negligence or greed I take someone’s health from them, of course, I owe them whatever it takes to make them whole. But just by my very existence as a physician, I haven’t taken something from a sick person. By my advantaged position I may have a moral obligation to help people who can’t pay. In fact, that is part of the oath that I took when I became a physician. But to say that I have an obligation is not the same as saying that the other person has a right.”

“But your profession was provided to you with the benefit of government grants and loans. So doesn’t it make sense that they have the right to enforce your obligation to the poor?”

“First, I didn’t go to medical school on government loans. I worked nights and weekends in the blood bank.” I didn’t add the haughty ‘I’ll have you know,’ that I was thinking.

“And even if I had, it would have been a loan that I repaid. So how does that make me indebted to the government?”

“The very fact that you came from a home that had advantages makes you indebted to society. You had parents that made you study and helped you succeed. Some people, typically the poor, don’t have those advantages. Is it right that you should have things that they don’t? And in the case of Haiti, isn’t it true that they are poor and disadvantaged largely due to the history of American imperialism, embargoes, and racism? So isn’t it simple social justice that Americans should be providing health care for the poor of Haiti?” It was clear that she meant this argument to extend to the poor in general.

“That’s an interesting argument that you make,” I said, trying to be open minded about something that I had settled long ago in my own mind. “It is true that I had many advantages, but they were largely due to the decisions and sacrifices that my parents made.

But they didn’t come at the expense of someone else. Life is not a zero sum game. My benefits are not always at the expense of someone else. And it is true that America has not always acted in the best interest of the Haitian people. But it is the obligation of the American government, or any government for that matter, to act for the benefit of their own people. That doesn’t justify some of the racist policies of America’s past, but it does explain some of the trade policies. So while I agree that the American government does owe it to the world to do justice and right the wrongs that it can, I’m not sure that that debt extends to me personally.”

“The government owes to the poor and disadvantaged the right of access to health care, wouldn’t you agree?” It was clear that she cared deeply for the poor and this made perfect sense that a benevolent government would provide for its weaker members. But what I heard was ‘access’, the buzzword that is used throughout the health care debate in America. It was the picture of a doorway to health that someone was blocking. But I could see that the ‘access’ debate was an attempt to shape an argument through defining the terms in such a way that no reasonable defense was tenable.

“You are right,” I conceded, “that no one should be denied access to health care. There should be no one preventing someone, anyone, from obtaining health care. You might be surprised to know,” I said, drifting into my professorial tone, “that it is illegal in the US for an emergency physician to ask about a patient’s ability to pay before providing emergency care. So I agree that it would be immoral and unjust to refuse to care for someone until they had proven that they had the means to pay.  But that does not mean that they are relieved of the responsibility to pay. Nor does it give them the right through the government to tax me to pay myself for that service.”

“You’re such a Republican,” she said with disgust before she could censor herself. She blushed at revealing her anger with me. I was older, after all, and the leader of the group. It was a conversation stopper, though.

Later she came to me privately. “I’m sorry I called you a Republican,” she said with sincere humility.

“You’re right, you know,” I said, chuckling. “But I never considered it an epithet. Don’t worry,” I reassured her, “we’re on the same side. We both want to make this situation right. We just haven’t settled on the right way to do it yet.”

Dr. Mark Plaster is the founder and executive editor of Emergency Physicians Monthly
twitter @epmonthly

 

Comments   

# Be Careful What You ReadPhD Student in Question 2012-03-14 02:58
As the PhD student quoted in this article, I would like to clarify that this article does not accurately represent our private conversation or my views on the issue. Much of what is written here, is not something that we discussed.
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# My Apology For Any Misrepresentati onDr. Plaster 2012-03-14 05:35
My deepest apologies to my friend, "the PhD student" referred to in my last installment of Nightshift, "The Wrong Right". The column was the result of a week long dialog with an incredibly intelligent and interesting student, and several others as well, that was condensed down from memory to a 1200 word space. I apologize to her publicly if I misrepresented her views. This and many other topics were discussed at length. I gladly admit that I learned more than I taught. I did not intend to demean her or her views in any way. If I did so, I apologize to all involved. The purpose of the column was to provoke a dialog on the topic of health care as a human right. See the discussion in Letters to the Editor in print. To that end, the column has accomplished its purpose. I pray that all will forgive any literary license that I took with the facts to stimulate that conversation.
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# No Apologies NecessaryA Real Doctor, Not a PhD 2012-03-14 11:03
No need to apologize, Dr. Plaster. What you experienced was a microcosm of the conflict that arises when one who lives by the motto "from each according to his ability, to each according to his need" encounters one who lives by the motto "life, liberty, and the pursuit of happiness." Don't forget that this conflict defined the foreign policy of two superpowers for much of the 20th century. Unfortunately, the foxes are now in the henhouse courtesy of various and sundry PhD factories.
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# Re: The Wrong RightDarrell Looney 2012-03-14 13:52
The problem with Health Care as a "Right" is that everyone is very willing to define it as a right, but no one is willing to discuss the RESPONSIBILITIE S that go along with that right. We all have the right to vote in this country, and the attendant responsibilitie s are to pay taxes and perform jury duty. How about a discussion of the attendant responsibilitie s that go along with the "right" of health care? Talk about that, then only silence is heard in the "Access to health care debate". Why? I suggest it is due to mostly economic reasons and the fact that no one wants to ask difficult substantive questions because it may make individuals look bad politically! The reality is that patients are held to no standards of action or behavior, therefore the ilk of Press Ganey and MedMal Lawyers can flourish like weeds by placing the onus to perform on the part of the health care delivery system alone, fertilized by the opportunities to exploit human shortcomings for economic gain. All the while, the only consistent outcome of doing things this way is an increase in the costs of health care in this country.
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# Your argument doesn't make senseJohn Grady 2012-03-14 19:43
To argue that everyone should have access, and we as EPs should be required to provide that service, with no thought of compensation is arguing against yourself. Why shouldn't we expect society to collectively pay for a service they already receive? Why shouldn't we get compensated for every patient we see? Why shouldn't we as a society pay for preventative care and primary care that is FAR less expensive than the emergency care we provide for those without REAL access to healthcare? You're old school mentality of doctor as capitalist is unfair to patient and doctor alike in an age of EMTALA, JHACO and a myriad of chronic diseases that are treatable.
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# Health care is a basic human rightDwight Burdick, MD, FACEP 2012-03-15 00:35
When I graduated in 1968, I swore a solemn oath, perhaps a bit quaint and dated, but an oath that I would dedicate my life to my profession, my colleagues, and my patients. In my interpretation of that which I swore to, was an obligation to my patient, but not a privilege for myself.
I have endeavored to adhere to this concept of obligation throughout my long career. Certainly, if am obligated to provide a service, that service becomes the right of every patient presenting to me.
For my profession, I would point out that whenever Physicians cease respecting our obligation, and instead insist on a privilege, we will inevitably loose our self respect and the respect of our community.
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# Patricia 2012-03-15 04:48
I think the dr. Misses the whole point....and is assuming the dr. Is the only one in the equation for " health care". He is making this argument about him, and it's not about him or any other dr. It's about civilized society that organizes in such a way as to care for it's citizens. We have a right to use the roads, drive on the highways, go to public schools, use the libraries , go to and enjoynthe national parks, but people like him want to end it there and deny the public the right to tax supported hospitals and other health care access points u less they can pay some exorbitant predetermined amount. This prehistoric and self serving attitude is contributing to the rise of the cheaper nurse practioner and physician assistant.....I MHO....we actually may get to a point where we don't even need a doctor anymore, here in FL the PAs are opening their own clinics cash pay for the people who are uninsured lots cheaper than a dr or having insurance. But if you subscribe to this guys opinion that health care is not a " right" in our country ( rights being only those things that we establish on a national level for our citizens) then what you are really saying is that poor people who can not pay for their health care should be allowed by this dr. to die . Unless the good dr agrees to a charity case here or there...oh wait he's off giving charitynto the Haitian citizens...I guess the patient just has to die....there are ways to organize this thing so we can be a civilized society and provide basic health care to our citizens...and for those dinosaurs who don't like it well maybe they can move somewhere where the wealthy can pay for their health care and the poor can wait for volunteers, maybe somewhere like Haiti. I don't sound pedantic.
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# Patricia 2012-03-15 05:07
I meant, I hope I don't sound pedantic. Or sarcastic for that matter. The comment above about people being responsible is well taken....which is what the affordable health care act does...tries to make people responsible for obtaining health insurance.
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# Thank you for the thoughtsQuestion 2012-03-15 09:23
Dear Phd Student and Dr. Plaster: Thank you for taking time to pose the question of health care access and for looking at how it affects both the patient and the physician. Do you think current health care reform moves closer or further away from what either of you would regard as the “best plan” for addressing concerns relating to this issue?
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# RespectRegular Reader 2012-03-15 09:42
Dr. Plaster: I respect your integrity in your response to the Phd student’s post. I was impressed by the maturity of this leadership.
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# Ted Switzer, MD, FACEP 2012-03-16 07:53
The article is brilliant and made me re-consider all sides in the question about health care in the United States ...and if it is a right. The issue can be debated ad nauseum but we, as a nation, decided this a few years ago.
In 1986 when Congress passed the Emergency Medical Treatment and Active Labor act (EMTALA), with no provision for compensation, we effectively decided that all people who live in the country have the right to an appropriate medical screening examination and stablization.
So, officially, there is a right to this limited form of health care in the United States. Beyond that, leagally speaking, there is no right per se.
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# What did your vow REALLY say?Pat Conrad, MD 2012-03-16 14:50
To Dr Plaster and other posters,

What oath exactly did you take? The Classical Hippocratic Oath does not obligate a physician to treat any and all.

Dr. Plaster, was the oath you took a variation on the Hippocratic one? The Classical Oath does NOT say anything about an obligation to treat regardless of payment, and only prescribes behavior between a physician and patient that have (implied) already entered into a voluntary association.

It is your own choice if anyone took an oath to treat without pay, but let's not confuse that with the original; as a profession, we have blurred the lines for decades and given lip service to something not even in the original oath, which in turn has been used by patients, hospital administrators, insurance companies, the media, and even ourselves to bludgeon us into de facto servitude if and when society deems it.

I enjoyed your well-written, very pointed article, but question this one assertion.
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# Other rights have dutiesSeth 2012-03-18 05:30
To play devil's advocate, we have rights to a trial by jury, which requires citizens to serve on juries; the right to a lawyer requires, well, lawyers
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# @Ted SwitzerJohn Grady 2012-03-18 07:50
Show me any hospital ED contract in the country that requires in writing (not even practice) only a MSE and stabilization. I can show you examples of Hospitals sued for providing stabization and then "discharging" patients to the street. EMTALA is only part of the picture, along with JHACO malpractice and hospital contracts we do have legal, moral and contractual responsibility to provide medical care to everyone who comes in our door. Read this week's Time Magazine article from Fareed Zakaria entitled Health Insurance is for Everyone for a more eloquent argument than I can put to keyboard.
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# pjk 2012-03-24 02:40
I spend my life defending Dr's, nurses and hospitals from Medical Malpractice lawsuits. I think many who are arguing in favor of universal health care here are completely missing the point. In his speech to congress on health care, President Obama stated that the biggest driver of our national debt and deficit was rising health care costs. He argued that the status quo would drive us towards disaster. So, what did the President and those brilliant democrats do? Did they craft a law that would truly "bend the cost of health care down"? You remember, the President claimed that his new law would insure 30-40 million more americans and at the same time LOWER the cost of health care. They had the bill scored by the CBO and voila, it proved that this bill was a miracle. It insured millions more and lowered the debt and deficit. WOW! But, how was this actually achieved? The CBO scroed the 10 year cost of the bill under the constraints it operates under. They are duty bound to accept the numbers given to them by congress. So interesting things happened. The CBO took the revenues of 10 years, but only scored the cost of 6 years of the new law. (a nifty little trick, don't you think?) Also, the Dems took $500 Billion dollars from Medicare and said they were using that to reduce the deficit. But wait, they were also using the same $500 Billion to pay for the new law? (I happen to have $50K sitting in the bank right now for next years tuition for my daughter. After I pay her tuition for the year, I am going to use that same $50K to buy that new Lexus I would love to drive. Neat trick, huh)

This entire debate is a DISGRACE! Had the President been HONEST and sold universal health care as a moral imperative that we would all have to chip in to afford, I would have supported his efforts. He could have gotten up before congress and argued that this was the right thing to do, but it will be expensive. Therefore, we are ALL going to have to pay a bit more in taxes to afford this. But no, they created this mandate which is in all likelihood unconstitutiona l.

So, guess what happened not too long after the bill was passed in regards to its ability to bend the cost of health care down?

http://www.nytimes.com/2010/04/24/health/policy/24health.html?_r=1

oooppps!

I represent some of the largest "safety net" hospitals in the country. These institutions do an amazing job providing health care to poor and underserved communities. Guess what? These same institutions are ALREADY being crushed by the regulatory and compliance costs of the PPACA.

In NY, where I practice, these safety net hospitals are almost 100% dependant on Medicare and Medicaid funding. In NY, The Gov just cut $2.8 Billion dollars from the Medicaid budget. Prior to the passage of the ACA, Gov Patterson and Mayor Bloomberg came out against the new law stating that it would add $1 to $1.5 BILLION in Medicaid costs to NY State.

For those here who support this new law and ACCESS to health care for all. PLEASE, PLEASE explain to me how a state that just had to cut $2.8 Billion from its Medicaid budget is going to pay for the added costs attendant to this new law?

We will never solve our deficit and debt problems until and unless we confront health care costs head on. Medicare/Medica id costs are exploding, and will only get worse as the population ages. Congress' heavy handed attempts to control costs by limiting doctor's payouts will not work, as many doctors are already refusing to see new Medicare patients. As a liberal Obama had a unique opportunity to fix this liberal program gone wild. He did not rise to this challenge. Instead the PPACA does nothing to control costs and simply adds another bureaucratic and costly entitlement on top of those we already can't afford. The deficit commission really ducked this one. The PPACA must be repealed and Medicare/Medica id block funded to the states, or we will never control our debt, even if every dime is simply confiscated from the rich.
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# pjk 2012-03-24 02:43
I realize my post was long, but I am passionate about this subject and deal with the pernicious effects of this new law on a daily basis.

I realized I was being critical without offering any alternatives to the new law; because I think we all agree that the status quo is unacceptable.

There are ways to insure more people and to bring costs down. Government has established and nurtured a system in which most patients are distantly connected to payment for services. This encourages them to spend without regard to expense. A lack of self-rationing increases demand, which drives up costs. Real progress, however, can be made in states where lawmakers have heaped very expensive mandates on health insurance policies.

In a few states, there are mandates that require policies to include benefits for Oriental medicine. Others require plans to cover hair prostheses. All but four states mandate that insurance cover alcoholism treatment while the majority of states require the same for drug abuse. A benefit for smoking cessation is mandated in six states while port-wine stain elimination is required in two.

In 12 states, insurance policies must include access to acupuncturists. Three states say plans must provide for athletic trainers, and dozens make insurance pay for a variety of marriage, occupational and massage therapists, pastoral counselors and social workers. Four states even require that insurers provide for naturopaths.

There are thousands of mandates at the state level. Most of the mandates cover common benefits or providers, many of the mandates are highly suspect. Few of these are costly by themselves; most increase the price of premiums by less than 1%. But when added together in a plan, insurance coverage becomes considerably higher.

When I was meeting with my clients that run the not for profit hospitals I represent, there were experts who came to us and lectured and demonstrated that getting rid of many of these mandates could lower the cost of premiums by 50%! The mandates are an insult to common sense. A single man does not need an insurance package that covers in vitro fertilization, maternity leave, a midwife, breast reduction or mammogram's. Neither is it necessary for a childless, unmarried woman to have a plan that includes care for a newborn and screening for prostate cancer.

And a teetotaler should have the option of choosing a plan that doesn't have benefits for alcohol and substance abuse.

In many cases, however, they have to pay for such coverage, either through individual policies or employer-provid ed plans. State legislators could restore good sense to the law and provide a genuine measure of reform by backing off the mandates and letting people buy from an a la carte menu of benefits and providers.

Why should health insurance not be sold across state lines? This lowers the cost for car insurance, why wouldn't it lower the cost for health insurance. This suggestion has been opposed by the democrats. Why?

Also, the costs of medical malpractice is hard to calculate. But, I can tell you from personal experience that Dr's and hospitals routinely order tests and prescribe medications as part of the practice of "defensive medicine". There must be Tort reform that makes sense. I am not advocating caps on damages. People who are injured through the fault of Dr's have a right to compensation without caps. But, I propose taking the cases out of the hands of juries. There should be specialized medical malpractice courts just as there are immigration and tax courts.

These are just some possible ways to lower health care costs and provide access to more individuals.
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# Let's take care of the basicsDr. Theo 2012-03-25 13:06
Before we argue about whether health care is a basic right shouldn't we take care of some other injustices first. I was downtown recently and i actually saw people living on the streets and under over-passes. Shouldn't housing be a right? Everyone should get a nice home from the government.

And what about food? Health care means nothing if you are starving. Everyone should get unlimited groceries and access to restaurants paid by the government.

Clothes? Is not that a basic human need that everyone has a right to? Clothes should be provided for free.

Transportation. Without a reliable car going to work or to the welfare office or to the doctor or to McDonald's becomes nearly impossible. Clearly, owning an automobile is a fundamental right that should be provided by government.

Contraception? Well,...I guess that's been argued enough already.
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# MDDr. Alan 2012-06-06 12:00
Remember in order to give something to somebody that they have not earned you must first take it from somebody that has worked for it. (or something like that)

This argument is not about basic human rights, its about giving free 'stuff' to people who have not earned it - therefore alleviating them of any need to work for it, and hence any desire to work for it.
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