The Ethics Committee 2

I'm following up on the ethics case that I wrote about a couple weeks ago, but it seems that one dilemma leads to another, and another, and another... What I find so interesting in this case (as in many of the ethical scenarios that we've been presented) is the issue of "justice." Who deserves our care? I think answering that question unfortunately depends so much on where you were born, where you grew up, who did this-or-that to you, etc. So much happens to us as children, things that we cannot control, that affects the rest of our lives. And then who are we to sit here and judge someone in the moment? This person gets another chance; you don't. We'll pay for your complex discharge, but not that other guy or gal's. When we really delve into some of these issues, I'm wrought with guilt. How did I get so lucky to be educated, to be loved, to not grow up in an environment wrecked with drugs and alcohol, to not be molested, to not have a serious psychiatric disease, to not have been physically abused... the list goes on.

In this case specifically, we have a patient who's undocumented. We don't know why he came to America. He's unemployed. He has no family. I don't know his story; I don't know what he's had to go through in his life. With the opportunities I've been given, it's unlikely that unemployment will be an issue I will struggle with (knock on wood), or that my family will disappear. I will always have a network of colleagues, a group of individuals that will pretty much guarantee me health care as long as I keep in touch. In our society, this undocumented person only gets emergent care. Is that just? We, who never have had to deal with these issues, make the decisions concerning allocations of resources. Who gets what, and when.

But, note the other side of the coin: the hospital in this scenario has a limited amount of money that can be used to provide services for patients just like these: persons with no insurance, no means of paying for care, no resources. Let's say it's 2 million dollars (and forget the question about whether this could be waaaay more money, because that's another whole "justice" question entirely). What if this single patient takes up a large percentage of that $2 million? What if his cost for care precludes other patients from getting care? Doesn't one have to start thinking about "justice" in a different way when many other people could be helped with that money?

This is one dilemma I've really struggled with during our bout with ethics this year. I see it as ethics in a vacuum vs. situational ethics. One option for this gentleman is to look for care in his country of origin (Tanzania), and then pay to fly him there. No follow-up, no problem. Much cheaper to the hospital than emergency dialysis three times a week. For some, that's good enough. In my mind, that raises a number of red flags. That solution is certainly good enough for the hospital, but is that necessarily the best for the patient? What if that country can't meet his needs after 1 week? Are we just packing up this man and sending him to his death? What if the plane is diverted and he dies en route?

But say this patient is taking up $1 million a year, half of the year's budget for these patients. How many other patients who are also desperately in need of care, are we missing? Do we give up on this one since there are so many in need? I just don't see a win-win situation in this scenario.

I think that's what I've enjoyed so much about our ethics curriculum: it's more questions than answers. My banter back and forth on this scenario does not do its complexity justice; I would defer to my more erudite colleagues. But, there's so much at stake when you're talking about patients' lives, and there are so many back stories, and we don't ever really get beyond the tip of the iceberg. I just think it is so easy to turn one's back to a patient in need and say, "Hey, just fix yourself. Why can't you be more like Joe-Schmo? He's doing just fine." It's just more complicated than that.

It's an issue of justice.