Thursday, May 29, 2008

The Ethics of the Hospital Safety Net (3)

This is the third in a series of occasional postings about the U.S. safety net system. (See previous posts here and here.)

Yesterday I met for two hours with staff at a safety net social organization in the Boston area. A small group of medical colleagues and I are scoping out a volunteer project to help the staff address mental health issues that impede work with their clients around the organization’s social mission.

The meeting provided a window onto the frayed condition of the health system safety net, and the heroism of those who work to plug the gaps.

The organization receives referrals of severely disadvantaged young adults from public agencies. It acts in the Statue of Liberty spirit, receiving all comers, unscreened. That’s what it means to be part of the safety net.

Recently a client who was secretive about substance use experienced a severe reaction to heroin and had to be rushed to the hospital. Later that day, after successful treatment of the drug reaction, but without any information from the hospital, the client returned. (Presumably the hospital was hamstrung by well-intentioned but clumsy privacy regulations.)

A staff member commented – “we aren’t a hospital, and we’re not health professionals, but society asks us to take care of situations like this.” We discussed other clients whose mental health and substance abuse conditions created challenges for the organization. Our discussion focused on how staff can best process the emotional demands of their stress-laden work, and on ways to promote development of new skills.

My colleagues and I were overwhelmed with admiration for the work done by the organization and its staff. We were all physicians. Regarding the medical ethics, the sixth principle in the AMA code of ethics states:
"A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care."
Not so for the people we were sitting with. They could choose not to have a job, but otherwise they had no choice of whom to serve. That receptiveness created the safety net for their clients and the state

By chance I wrote this post in a classroom at Harvard Medical School while the first year students were writing their final exam essays for the "Medical Ethics and Professionalism" course. Classes, articles and lectures are all good sources of learning. But the students and their teachers know that the crucial ethical learning occurs in their front-line care for sick people and efforts to improve the organizations and systems that provide health care.

I left yesterday's meeting wishing that more political and health system leaders would sit with front line safety net workers, and, better yet, have experiences working side by side with them. It is hard to come into contact with the nitty gritty realities of human need without being changed.

For health system leaders, it would be harder to insist on the necessity of providing a high cost technology that provides minimal benefit after seeing our underfunded safety net system up close. For political leaders, it would strengthen their understanding of the opportunity costs of runaway health system expenditures, and perhaps their readiness to tackle the knotty political challenge of reallocating our societal resources. Allowing a bloated health sector to starve the social sector is not something we should accept.