This issue, I confess, sits in a very prominent fold in my mind. I debate myself about it constantly. On the one hand, I'm thrilled by the fact that Obamacare assures health care coverage for all of us, even our most disenfranchised. On the other hand, this positive embrace is clouded by the reality that most of our health care issues are self-generated. I am very resistant to paying for someone else's dereliction when the choice to be healthy or not to b healthy is obvious.
This perspective arises from many experiences. A powerful one occurred a few years ago by my involvement in the care of an 18-year-old boy who presented to the Stanford Emergency Room with fever, shaking chills and heart failure. Our diagnostic sleuths quickly diagnosed A.B.E, acute bacterial endocarditis, an infection of the interior of the heart by an invading bacteria.
It quickly emerged that he was an IV drug user, and therefore at increased risk for this potentially fatal complication. Even with appropriate high-dose antibiotic therapy, his infection destroyed one of the valves of his heart, and an emergency replacement by a member of our skilled cardiac surgery team repaired the ruptured valve. This serious plumbing issue was mechanically patched.
He did very well postoperatively and went home. But in two weeks, he was back in the ER with the same presentation, another batch of antibiotics and another surgical valve replacement quickly followed. This time, however, a clever house resident, in caring for him in the medical floor, discovered that he was dealing drugs while in the hospital bed. He was selling and self-injecting. A stern stringency was applied.
He went home. This time he was away for five weeks, and then reappeared without surprise. His case represented a stern challenge. The medical system was supremely effective in dealing with the health aspects of his case, yet frustration and even anger were generated by our inability to address the social pathology.
We presented his case to our graduate medical grand rounds in the effort to get some consensus. Did he need a cardiac surgeon or a sheriff?
It happened that he was then absent to our care for several months. One of our eager residents had the initiative to call Los Angeles County Hospital, and indeed there he was, now their burden.
Certainly, an aspect of his care is financial. His hospital bills at Stanford were picked up to the tune of $600,000 by Medi-Cal. Who pays the bills for Medi-Cal? You do. I do, we all do. So does his intrinsic right to medical care qualify him for infinite free medical response? Does responsibility trump rights? I wrestle with this dilemma.
What is society's responsibility to pay for someone's destructive behavior? I have no argument with the individual's freedom to own their body. But just don't send me the bill for your decision. What about smokers? High rise construction workers? Obesity? Certainly, they all are financial risks. Who pays this bill? We all do.
Several years ago while debating this issue, I contacted Norman Daniels at Harvard, who is one of our major bioethicists. (1) His immediate response to me was, "You can't blame the victim. Society bears the collective responsibility for all of its citizens, regardless of behavior." His feeling is that behavior is indeed a byproduct of the whole system, and any associated costs should be shared by all.
Is this true?
My debate goes on.
Daniel N. Just Health. Meeting Health Needs Fairly 2007 Cambridge Univ Press.