The Ethics of the Hospital Safety Net

Yesterday the Galveston County Daily News published an educative but heartbreaking story about the ethics of the hospital safety net.

The University of Texas Medical Branch (UTMB), the oldest medical school west of the Mississippi, has been known for its commitment to treating the medically underserved. It is now, however, considering refusing to provide cancer care to indigent, undocumented immigrants.

They must be monsters. Right? No. Wrong!

Almost 25% of the Texas population is uninsured. Medical costs are going up, the number of uninsured is rising, and state funding has been cut. In an effort to control costs the hospital laid off 381 workers last year.

This is, alas, a recurrent challenge for safety net hospitals. We look to them to be the caretaker of last resort, cut their funds, and then blame them for heartlessness.

UTMB is doing citizens and decision-makers a service by bringing the ethical challenge to center stage. Of the action they may take, their own spokesperson says – “it doesn’t feel right!”

Howard Brody, the distinguished director of the UTMB Institute for Medical Humanities, put the ethics cards on the table:

“If what voters of Texas want is Harris County [which would receive patients UTMB did not care for] shouting at Galveston and Galveston shouting at Harris County and everybody pointing fingers and saying ‘You should be doing more than you’re doing,’ then they can have that…If they want indigent folks to get care and want everybody in Texas to at least have a chance to have more access to medical care, then voters of Texas should step up and provide more resources.”

We ask safety net hospitals to turn somersaults on behalf of needy patients. That mission draws idealistic young physicians and nurses to work at safety net sites. But a point comes when trying to do the impossible turns into enabling. That is what UTMB must have concluded.

The Texas public is the legitimate decider about safety net funding. It is entitled to cut funds to the point where people with cancer will be turned away. But if it chooses to do this it should acknowledge the actions it is taking and the consequences of these actions. UTMB’s actions clarify the ethical dimensions of the policy debate and forces the public to own up to the implications of its funding decisions.