Tuesday, November 11, 2008

Hospitals, Ethics, and the Uninsured

Three cheers for print journalism!

For a rich understanding of the human impact of not having health insurance, look at the superb (but long - 5,000 words each) articles in Sunday's Washington Post and New York Times.

The Post describes a three day "medical camp" at the Wise County fairground in southwest Virginia run by the Remote Area Medical Volunteer Corps. The Corps provides free medical services to under served rural areas - initially in developing countries, but now in the U.S. as well.

Wise County is poor. Coal industry jobs are dwindling. The average income is $14,000. Medical care is scarce. Uninsurance is high. 2,700 people were treated during the three day camp. A 60 year old woman was treated for out-of-control diabetes. A man in his 50s had an egg sized cyst removed from his face. So did his son! A 31 year old woman who was born with a cleft palate and had not been able to afford dental care as an adult had her diseased teeth removed and was fitted with a special denture.

Rotting teeth, a disfiguring facial cyst, and out-of-control diabetes are shameful anywhere, but especially in a developed country. But the Times' description of how uninsured immigrants are often shipped home is more shameful yet. Sister Margaret McBride, a vice president at St. Joseph's hospital, from where 19 year old Antonio Torres was sent back to Mexico in a coma, put the dilemma this way:
"We're trying to be good stewards of the resources we have...We're trying to make sure that the acute care hospital is available for individuals who need acute care...We can't keep someone forever."
There's no overall policy or common approach to the situation and little support for institutions caught in the middle. Each hospital is on its own.

The volunteers who provide free outpatient services in Appalachia can make a gift of their own time. But hospitals have to pay for the beds that are occupied out of their limited resources.

I doubt that Sister Margaret is a worse human being than the volunteer surgeon who removed the egg sized cyst. From the St. Joseph website I learned that it is a 113 year old not-for-profit hospital. Here are excerpts from its mission and vision statements:
"[St. Joseph's]...affirms the dignity of the human person and the sacredness of all life. We exist to foster the healing ministry of the Catholic Church...we will:

* Deliver compassionate, high quality, affordable health services

* Provide direct services to the poor and advocate on their behalf

* Create partnerships that improve community health.

We believe:

...In the sacredness of all life, and therefore in the dignity of the human person and the promotion of human wholeness;

In a spirit of mercy that cares for the suffering and the dying;

In a spirit of hospitality that welcomes all in need;

In the rights of all persons to quality health care and our responsibility to act as advocates for the poor and those with special needs;

In the stewardship of resources for the enhancement of human life..."
I'm not cynical about St. Joseph's values. But if all they did was ship Antonio back to Mexico without picketing the state house they have failed their own commitments. Hospitals like St. Joseph's are in an impossible situation. They can't on their own make up for what our national and local safety net doesn't provide. But sending a comatose young man out in an ambulance isn't just harmful to him - it's corrupting to those who carry out the process.

We in the U.S. need to take responsibility for situations like Antonio's in a systematic manner, rather than leaving things to each institution and hoping for miracles. Happily, on Monday the AMA House of Delegates voted to gather the facts about forced repatriation and develop a policy to advocate for.

Hospitals can't solve the problem by printing money. But health care institutions can't repatriate sick people without losing a piece of their soul with each episode.

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