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Resource Utilization by manipulative intent: contrived access by illegal aliensPresented by Mike Rie Mike Rie: Here we go again. A 7 year old Bolivian girl is in Mount Sinai Hospital New York City. She got here with a tourist Visa and went straight from the airport to their ER. She has a spinal tumor and would need surgery and chemotherapy. Hospital will not permit surgerywithout 250,000.00 dollars from somewhere or somebody. They publicly state that they should not give free care because they can't afford to take care of people in their own catchment area and Medicaid is being cut back. The New York Daily News says that if she had entered the USA illegally she would qualify for Medicaid. Ultimately, the Actress marlo Thomas picked up on the media coverage and had the child transferred to St. Jude Hospital for treatment where she died a short time later. Should Mt. Sinai Hospital have treated this child as a humanitarian gesture? Marjorie Lazoff MD: What's the key issue? Is this scenario being exploited by Mt Sinai as a way of popularizing the proposed Medicaid cuts? If so, even if they're up against a legislative deadline I think Mt Sinai would have been in a stronger position if they first cared for the 7 year old with cancer and then presented the bill to the American public, asking, "our hearts won't let us withheld treatment, but our present government reinbursement doesn't allow us the money or resources to absorb the costs for her care ourselves. And if we can't afford her care today, and the cuts still keep on coming, how are we going to afford to care for others who can't afford to pay tomorrow -- like those who live across the street from our great hospital?" It strikes me that to hold a little girl with cancer medical hostage until her parents, or the US government, or someone, comes up with a quarter million -- or promises not to cut back on medicaid reinbursements -- is cruelly melodramatic. To most of us, a seven year old of any nationality with a treatable cancer is a medical emergency, in the ethical if not the medical sense of the word emergency. Regarding non-life/limb-threatening care of non-Americans, I think it's reasonable for a hospital to help arrange for such care in the patient's country or to seek out international organizations -- regardless of ability of the hospital or this nation to pay. America isn't obligated to care for the world, but in humane celebration of our relative good fortune we ought to fully support those international organizations that do, and squeeze every cent from our own medical banks to benefit others when we can. David Crippen: I don't know, MM, I have been thinking about this and I feel a bit of a hard-edge coming on. There is one big unanswered question here. Everyone that has contributed to this thread thinks they know the question but I have not heard it articulated. Was this a deliberate move from one government to manipulate another government into free services using a calculated assessment of their weak point? Or is this a desperate humanitarian effort on the part of apolitical individuals to help a needy individual for which resources are not available at home? The answer to this question determines how I react to it. I looked all over my messy office today trying to find an article in the American Journal of Emergency Medicine several years back titled The Moveable Medical Paradox (or something like that) by a guy named Reich. Reich-WT, The movable medical crisis: a parable in critical-care medicine. Am-J-Emerg-Med. 1984 Nov; 2(6): 550-3) It was a story that went like so: A plane with Central American registration lands in a mid-sized Florida city on the coast after flown under radar. The pilot wheels out two Central Americans in wheelchairs and calls a taxi. The taxi proceeds to the local hospital where the two ill-appearing people are quietly ensconced in the Emergency Department waiting room. The pilot quickly departs and flies out again under radar cover. Several hours later, the two are discovered and checked into the ED because they look sick. They are sick. Each has acute renal failure and numerous other diseases of a chronic nature. They need chronic dialysis and LOTS of medical care. The hospital conservatively estimates that it will cost them $250,000 per patient to get them into shape to deport. They go completely bananas (so to speak)and they try every way they can think of to get rid of them. But there is no way. They are too sick to transfer to a "teaching hospital" several miles away. The COBRA laws get in the way. Can't transfer them until they are "stable". Getting them "stable is the problem. Now the story gets interesting. Creative ways out....lets see now.....Yanqui ingenuity....we'll build a critical care transport team specifically for the purpose of transporting patients just like them. Patient's we don't want and will cost us money we won't be reimbursed for, but are too unstable to transport. So we call up the neighboring teaching hospital and inform them we are bringing them two great teaching cases.....not just "bringing" but "transporting" via our new handy-dandy Critical Care Transport team...complete with lots of personnel and goodies to insure that the patient is delivered in "stable" condition. Midnite Marj, with her usual concern for patient's welfare coming before political pooh-bah, would say simply: "Damn the reimbursement.....take care of the patient!". Shortly thereafter, the hospital wonks responsible for making the hospital stay afloat would faint dead away, or jump out of the 13th floor. No note. I don't think resource issues can be as easily dismissed. If this was a calculated move to abuse our resources, I am not sure we should have to buy into it. If it was a humanitarian gesture, then I must ask after our priorities. If we are into humanitarian gestures, should we not begin at home? What do we owe foreign nationals deposited on our doorstep in relation to what we owe our own needy citizens? Who should make these decisions? Of course it is perfectly predictable that Danny Thomases daughter would identify this child as a high priority for deviating from the usual resource allocation scheme we use in the USA. The affluent tend to mobilize large amounts of money to save the lives of identifiable individuals who have the benefit of wide media coverage. Witness the distribution of photographs of sad appearing children with appeals for funds or organs for transplant. Those who would "give" in such a manner require an identifiable form and substance which they may proudly point to and say "I gave of my resources to help this particular needy person". In this way they gain some immediate ego gratification and also, in some way feel that they have directed the utilization of their gifts. Those with less identifiable disorders, or those merging more with the great unwashed are ignored. Does this mean that this child was in any more need than the great unwashed who suffer daily? I do not mean to sound trite. This is a tough issue, and like most tough issues, the answer might not be the easy one. Marjorie Lazoff: DD, I don't know why you bring it up, since I am not unique in my "concern for patient's welfare coming before political pooh-bah" Do you disagree that to support political pooh-bah before patient welfare may be from other perspectives appropriate, but not from a physician's perspective? I'm not convinced we Americans understand the difference between a true 'limited medical resources' crisis (aka Bangladesh) and the compromises being forced upon us by the greed of self-interest groups as they try to insure the medical feeding trough continues to financially support many businesses comfortably -- aka pharmaceuticals, insurance, managed care and hospital administrators, organized medicine (AMA et al) and individual physicians, and medical supply companies. I didn't support Clinton's health plan because it seemed to me little more than a way to appease these groups while holding down health care costs, rather than deal with the deeper financial issues: the inefficiencies that make for clumsy paperwork, maldistribution of health care facilities and personnel, inconsistent medical care, and unrealistic government reinbursements. (Obviously it's not uniform: there are greater and lesser examples within each group, businesses and individuals who have not made their service obligations subservant to their acquiring and maintaining wealth. But from my vantage point that's not the overall direction the medical industry, in concert with the federal government, is taking.) It's against that personally-held belief backdrop that I look at Dr. Rie's dilemma. Maybe it's that St Jude's has taken this opportunity to both 'do the right thing' and project a favorable image of themselves doing the right thing. Of course, for all any of us know, Mt Sinai may (or would) have been refused by St Jude's when approached behind-the-cameras. And for all any of us know, Mt Sinai has no political agenda but may be so far in debt that its endowments are dried up, its top administrators are working gratis this year, and a quarter of a million dollars would irreparably crush them and their patients to the extent that caring for the child was truly financially impossible. Yes, it may be her parents always wanted to come to American and fill their pockets with our generous welfare system dollars, and took their daughter's cancer and inability to obtain treatment in Bolivia as the perfect opportunity to 'milk' America under the guise of humble parents so distressed they'll try anything to save their daughter's life. DD, there will always be people who will dump their problems on others rather than take control of their lives. As we know, sometimes they do so out of laziness, sometimes they do so out of depression, sometimes they do so because they can't think of another alternative or don't know what else to do. It seems to me our goal as physicians should be to help design a medical system that doesn't ENCOURAGE abuse. But whether such a system is in place or not, I don't think we should ever waste time ferreting out and destroying ONE BY ONE those who dump their cancers or renal failures at our medical shingles. My bottom line: I genuinely don't care why the parents brought their child here. A physician (or, by extension, a hospital) needs a reason before treating a 7 year old with cancer? Worse case scenario: America is used by two greedy foreigners looking to save their own money on their daughter's cancer treatment. (I trust the astute investigation journalists at Hard Copy or Day and Date will let us know if that's the case.) Best case scenairo: America's medical system saves the life of a little Bolivian girl. David Crippen:
>I'm not convinced we Americans understand the difference between a true
>'limited medical resources' crisis (aka Bangladesh) and the compromises
>being forced upon >us by the greed of self-interest groups
>Maybe it's that St Jude's has taken this opportunity to both 'do the right
>thing' and project a favorable image of themselves doing the right thing.
I have no doubt that St. Judes does admirable deeds, but they, and other facilities like them, cannot be counted on in the clinch. Projecting an image of themselves doing the right thing is the whole point; their political agenda depends on it. But it do
esn't not impact the big picture, so their efforts don't count in discussions of policy. They are funded differently that Sinai and are more resistant to financial shellshock because of their endowments.
>My bottom line: I genuinely don't care why the parents brought their child
>here. A physician (or, by extension, a hospital) needs a reason before treating >a 7 year old with cancer?
Ah Ha! I was waiting for this! (pounce) I have always thought that there is a place in the world for selfless altruism and unfettered devotion to those less fortunate. But such services STILL HAVE TO BE ADMINISTERED SOMEHOW. So if you were King, how
would you administer altruism? First come, first served? Tearjerker quotient? Age, IQ, sex, physical characteristics? If you had control over 10 widgets and you had a population of 20, all of whom wanted a widget, how would administer them? The sad f
act is that you don't have enough widgets to go around and you MUST administrate them somehow. You cannot please everyone. No matter what you do, someone will be left out in some fashion.
Well, to get a hint, I suppose you might look around you and see how others administer their widgets. If you looked at the former USSR, you would see that they use the "Service Merchandise" method. All comers take a number and wait till their number is
called. No one has priority, everyone is treated the same, but everyone waits. The more demand, the longer the wait. In the United Kingdom they (ostensibly) use the "fair distribution" method. If you have a population of twenty, and you have 10 widget
s, you give everyone half a widget. No one can complain that someone got more, but no one is completely satisfied. In the USA, we prioritize. If you have a population of twenty, we prioritize such that a sub population of ten get a full widget and the
rest go without. Yes, some gets and some gets-not but half the population is satisfied. (The other half go to emergency departments and get their widget through the back door).
So, if you were kind and it was up to you to divide up the widget, how would you do it? Are you willing to take resources from the population of patients that DEPEND on Mt. Sinai and give them to someone who is cutting in the line? You're holding the wid
gets and the Sinai neighborhood kids are gathering in front of you for the news....
Marj Lazoff:
I've said nothing about selfless altruism or unfettered devotion to those
less fortunate. I've said that a physician -- in contrast to an
administrator or politician or general citizen -- ought not to judge the
appropriateness of rationing or providing care for a patient, but only
provide such care on demand.
Two people come into the ED, both with gun shot wounds. The story is that
one was robbing a store and in the process shot the storekeeper, then was
wounded himself seconds later by the same storekeeper defending his turf.
Both need immediate medical attention, but there is only one OR ready to
go -- both will get care, hopefully neither will die, but which will get
PRIORITY care?
Would you agree that the appropriate course of action is to do what's done
at present thruout the country: to triage both patients based SOLELY on
their medical needs, use the available OR on the patient most
salavageable/least able to physiologically tolerate waiting for the second
room to be ready, and allow the police and judicial system to sort out the
legal issues later?
(Lest our priorities change as often as the scenarios change -- we could
hear later that the store was really a drug front and that the 'robber'
was a customer whose loved one had just OD'd because the expected purchase
was knowingly cut with a toxic substance. Or that the storekeeper was
blackmailing the perpetrator, or that the perpetrator was an otherwise
wonderful person sadly suffering an acute psychotic break.)
My point: society should not expect (in fact, should specifically
discourage) a physician involved in deciding who is deserving of care. We
should treat whoever is before us, however they got there, and our role is
to make it as easy as possible for all who desire care to be seen. I
personally believe if we prioritize patients and not special interest
groups we will find enough money to avoid most of these horribly difficult
rationing situations, but that's a tangential point. Whatever, I think our
physician role is not to assist in determining rationing based on
financial realities but to inform the country what our health care needs
are and the expected medical ramifications of proposed rationing
scenarios -- none of which are good news.
I haven't as yet read an argument here convincing me otherwise, which I
anticipate would take the following form: the role of health care rationer
is in keeping with the concerns of a clinician (patient-centered
physician). Rather, I continue to see the role of rationer as antithesis to
those concerns, since they involve medical management with other than the
patient's best interest at heart.
Understand, DD, the distinction between the above comments and my
recognizing when rationing is necessary and how it ought to be
accomplished. Of course I have an opinion as a private citizen what we
ought to do with little Bolivian girls with cancer -- which I've already
expressed -- as I have an opinion on what we should do with widgets if I
were King. But to me such opinions are completely, and necessarily,
distinct from my physician persona and so have no place in this particular
thread.
David Crippen:
In essence, you seem to make this a problem in triage. OK, let me
construct the following scenario and you tell me how you would handle it. You are busily at work in your ED and there is a line of people waiting for
services. The ED nurse is busily deciding which ones will be prioritized
for immediate, delayed and no care. Into this line......at the head of the
line...... blusters a Bolivian family and they confront you. The following
conversation ensues:
Them: "Excuse me, Miss.....We want some service".
You: "Don't you see this line? See the triage nurse".
Them: ""Well, that's all very nice but we are in a hurry. Our daughter
here has a life threatening illness, we just swam in from Bolivia and we
need to get down to the welfare office before it closes and get these
children registered in the local school. Our kid needs to be seen ahead of
these others because she's sicker than them".
You: "We have rules to insure that things proceed effectively here.
You'll have to play by the rules". See the triage nurse...he/she will
determine your place in line. That is the way we do business here".
Them: "Your rules don't apply to us. We don't have any meaningful care
for our sick kid's particular problem in Bolivia. We have gone through a
gamut of fear and terror at the hands of the Immigration and Naturalization
Service.......we have run from dogs and we've been shot at. We have
survived this trial and now we are here in the land of plenty. We DESERVE
to be seen before these others because we have endured many more hardships
than they. "
They refuse to move from the head of the line.
Marj Lazoff:
You misread me. I agree the problem is not 'in triage' but in (what sounds
to me like advocacy) physicians deciding who to treat based on non-medical
parameters like nationality. Hospital administrative policy may restrict
care only to people with green hair if it likes, but a physician faced
with a blue haired patient cannot, in my opinion, ethically refuse to
treat such a patient simply because of hospital policy, unless care is
effectively (not just pretended to be) transferred.
If the physician suspects a ruse, that's a separate problem distinct from
the medical condition which needs to be addressed in a more appropriate
place and time. We ought not punish patients for their, and certainly not
for their parents', acts by withholding medical care. There's other ways
to punish such individuals, legally.
I'd like your opinion again on my GSW scenario, but from the above
perspective: should triage decisions be the sole factor, or should bias be
introduced in favor of the storekeeper, given limited OR availability?
This scenario seems to me a realistic, straightforward way to discuss
whether physicians should be using non-medical or only strictly medical
critera in rationing care. (We're taking a leap by assuming medical care
needs to be rationed, but let's take that leap so as to advance the
discussion).
As to your ED scenario, the Bolivian family acted not in accordance with
ED protocol and did so without medical reasons -- and therefore they would
either need to cooperate or be escorted out of the ED until such time they
did cooperate. I hope your scenario doesn't represent biases against the
Bolivian family in the real Mt Sinai case, who was refused care by the
hospital without our knowing how they acted in their ED; in fact, the
reasons given for refusal were purely financial (political) and not
behavioral. Several here have suggested the family knowingly came to the
US looking for a free handout. That's possible, perhaps even statistically
likely, but I'm curious if that is based on specific facts in this case or
an underlying prejudice ("common sense") regarding those who come to the
US seeking lifesaving care.
David Crippen:
But I recall you stating that your personal preference in dealing with patients is "first come-first served". You don't prioritize on the basis of political correctness. If they show up, you treat them and let someone else worry about the why and wherefo
re. You don't make political decisions but you expect others to. That's OK but someone, has made the decision that it is inappropriate to expend taxpayer resources on this patient. You don't seem to agree with this, so you are making defacto decisions a
bout politics by proxy.
You say Hospital administrative policy may restrict care only to people with green hair if it likes, but a physician faced with a blue haired patient cannot, in my opinion, ethically refuse to treat such a patient simply because of hospital policy, unless
care is effectively (not just pretended to be) transferred.
But if those are the rules of the game, you MUST refuse to treat a blue haired person if they arrive and request to play the game outside the rules. Otherwise, there are no rules and the strongest get their share first. I (ahem) know a lot about civil d
isobedience, and I can assure you that the fundamental principle is that the personal disobeying must take full responsibility for his/her actions, and hope that society sees the light from his/her actions and change policy accordingly. If you treat a bl
ue haired person against official policy, you will probably get canned. Then, your only hope is that more people disobey on principle, and that society must change as a result. Are you willing to do that?
My opinion on your Gunshot analogy? I would treat the most urgent case first. And I don't think that these scenarios have anything to do with each other. Yours is purely clinical and mine is purely political.
How would I deal with the Bolivian girl? Her condition is not immediately life threatening. I would inform them that the services they request are provided by a taxpayer base for members of the community served by that tax base. They do not belong to t
hat tax base. To use those resources deducts the amount of real resources available to the community supporting it. Period. I would then refer them to the administrator on call to determine if there is some compelling reason why an exception should be
made. If those responsible for making policy decide to make an exception for whatever reason, she's in. Otherwise..........back to Bolivia.
Dick Burrows:
Whether anyone likes it or not, it is fairly self evident (at least to
me anyway) that when the bean counters/politicians/purseholders say
there is not enough to give everything that everyone wants to
everybody when everybody wants what everybody else wants (as opposed
to needs) then there are going to be unpleasant, distasteful
casualties. One side or the other is then going to rend garments and
cry "foul" or "fiend" depending on which side the antagonists stand.
It's a war! You fight wars to win. You don't win wars with ethical
rectuitude. The first casualty of war is ethics. Like any Third World War will likely rapidly escalate to the final nuclear solution, this war has been rapidly elevated to the need to turn the patient into an ethical football kicked from Administrativ
e
man to Medical Man and back again. It was/is inevitable. It will get
worse.
The child will be used again and again as the child hits at the heart
of the soul. It happened in Britain when a child had leukaemia and
the local authority said enough is enough.
It will happen again. It's not logical either as a seven year old and a seventy year old
may both have equally hopeless prognoses making treatment as near
futile as makes no difference. But then who said war was logical.
It is a war
The next tactic of war is the nasty one - discrimination. They don't
belong to the club (American, British, Protestant, Catholic, people
with glasses etc.) - out with them! America is not no less
susceptible to this than the rest of us - when you consider the
internment of Japanese Americans following Pearl Harbour and the
excesses of McCarthyism. You really have to guard against and watch for this one - it is subtle, vicious and persuasive. It is a war - you need strategy.
I think you are fighting a very dangerous battle when you refuse to
treat people on any grounds other than those of futility. And that's
difficult enough. Let the politicians and bean counters sort it out. They won't, they
haven't and they never will - but it's their bloody problem. Yours is
only one of being asked to do something without the necessary
resources so futility becomes triage. C'est la vie C'est la guerre.
Miles Jones:
This case was a text book dump and it worked. Whoeversent her from SA
to the US knew what they were doing. Why not send her th Cuba or
Russia or England? Answer because she would not get the care.
Americains CARE! Even if one place refused the spin doctors would make
it happen because the first no would be made out to be a coldhearted
bean counter. Proper way to say no is to say I can't but I will find
someone who will. If our first MD had call MT with the request she
proably would have said no. Now you have an out You tried to help but
just couldn't and the people who could woundn't. That's how you win
the PR game.
Dick Burrows:
I hope you are not suggesting that the National Health in the UK and
the people working in that system are uncaring people. Because if you
are I would suggest that you are talking a load of crap.
Political events in Cuba, Russia, Germany, South Africa and elsewhere
have shown that most people are the same the world over - they
differ because political systems, commissars state propaganda or
whatever, in many ways force them to be different.
You can argue that no American would allow or get up to the shit that
other countries allow or get up to - but it may be simply a question
of scale - Tienamman Square/Sharpville versus Kent State - McCarthyism
versus Stalin's excesses. Ku Klux Klan versus the Broederbond. And
then there was Mi Lai!?
There have been a number of patients sent to the great US of A from
this country. Cost the relatives a fortune. Cost everybody a
fortune and for what. Very little was achieved. High tech medicine
such as liver transplantation, heart transplantation is available but
has to be very tightly allocated (not necessarily properly) When the
transplant team says no it is not without a lot of soul searching as
to the 'rightness' of the action. They are not 'bean counters' just
because they said no. Some "Caring" Americans seem to forget to
consider the fact that there is more to the abstract phenomenon of
care than the "technological imperative" to deliver high tech
treatment.
As with the rest of us, you Americans are struggling to get the
answers and the issues are exquisitively difficult but to imply that
Americans are the only ones who care is not helpful. Neither is it
correct correct or fair.
Louis Brusco:
Hospitals in NYC are in extremely precarious financial shape. In
addition to all the managed care burdens which have hit all over the
country (and are starting to hit in NYC right now), we face the spectres
of the Gingrich promised Medicare cuts; severe cuts in the NY State
Medicaid reimbursements, declining reimbursements for charity care,
infusions of uninsured illegal aliens, and a promised July 1 sudden
deregulation of all hospital rates. Hospitals like Mt. Sinai are facing
HUGE operating deficits for the coming years. My own hospital has a $30
million hole to fill!! You cannot continue to take on all comers and
hope that someone will pay, or that you can foist off the costs onto
patients with private insurance anymore. Almost without exception, all
the hospitals in NYC are refusing to care for non-emergent patiens who
are uninsured and do not live in their catchment areas; it is one of the
only ways to survive. Why should the hospital spend the money on that
patient if it means that some nurses, etc., might have to be laid off and
care sufffers for other patients?
Jeffrey M. Rosenberg:
This is clearly a difficult situation. But what happens here may set a
precedent for the future and this is the danger. Are we going to see a
mass of ill patients from foreign countries arrive for medical care since
this girl was successful in obtaining treatment? Perhaps the government
should pay for the girl's medical care and deduct that amount from the aid
package sent to her country this year-I bet that the foreign governments
would provide medical care to their citizens on their own soil.
Mark Wedel:
Re your comment " But what happens here may set a precedent for the future and this is the danger. Are we going to see a mass of ill patients from foreign countries arrive for medical care since this girl was successful in obtaining treatment?"..... I'm
afraid this poor Bolivian girl isn't setting precedents for anyone. Instead, the precedent has long since been established. We have 3,000 illegals per night coming across the southern California border. Included in this 3,000 is a substantial number of
gravid females, waiting for the first suggestion of labor and then heading across the border and up the interstate to either San Diego or Oceanside where they check into the first hospital they see - sometimes having already delivered, sometimes just in t
he nick of time. It's so routine that its a fact of life here.
Meanwhile, the press mocks Pete Wilson's pleas and lawsuits against the fed that simply ask for border protection, and the media scorns a Pat Buchanan for being so impossibly nationalistic in his demagogery. For once the problem strikes a northern state
instead of Florida or California, and suddenly there's a lot of folk all riled up I concur with those who've suggested that this is a political problem, not a health care professional's problem. Perhaps your proximity to the White House will finally get
the message home to someone who ought to be giving the problem some attention instead of lipservice. Meanwhile, we continue to provide the health care to these patients, pay the taxes for what they cost us, and recognize their offspring's constitutional
right to US citizenship. What a country. Welcome to the club!
Marjorie Lazoff:
If your prediction holds true and there is such an exodus from other
countries to American hospitals, then I hope (by that time) we have some
structure in place, either nationally or preferably internationally, to
deal with those families better than we've dealt with this. And I agree it
should involve money from someplace other than the host country. It might
be more diplomatic not to publicly humiliate another country by 'billing'
Bolivia the first time out -- unless we discover the government sent an
expensive health care problem to us in this manner deliberately.
But I strongly agree with you that this situation be our 'wake up' call,
so we not get caught off guard again. Sadly, I doubt it. I wonder if we
can rise to the occasion and recognise this as an opportunity to address
a previously hidden international problem in maldistribution of health
care, to which all countries with the advanced facilities and humanitarian
bents might (as a group) respond.
Tim Buchman:
One appreciates the outpouring of emotion and the magnificent mobiliztion of
resources on behalf of the young girl with the spinal tumor. It is also
important to separate principles, facts and opinion.
Whether the family came hoping that the media coverage would trigger a
philanthropic gesture or whether the family came hoping/expecting that the
citizens of the United States would pay to attempt to cure their child is
beside the point. They came hoping to get something for nothing. From the
standpoint of economics, it makes little difference whether they hoped to
obtain mineral rights in the desert, medical care or $250,000 in cash. It's
still $250,000 in resources.
They had at least some reason to expect success. The U.S. has a long--and
proud--tradition of providing assitance to foreign countries and also of
welcoming immigrants whose lives are (politically) threatened by their home
governments.
The questions the members of this discussion group might consider are the
following:
Marjorie Lazoff:
But the 'resources' are to rid their little girl of cancer -- they didn't
come looking to invest a quarter million in T-bills. I resist looking at
this from the standpoint of economics; that kind of simplicity risks
distortion because it ignors the political, emotional, live-threatening,
AND financial complexity of this situation.
Two points: first, none of us know the financial capacity of the family.
We assume they came here planning to pay 'nothing' yet that might not be
the case at all. Perhaps they sold their last goat to get the airplane
tickets. Perhaps they are middle class in Bolivia and came checkbook in
hand, willing to pay tens of thousands of dollars in care -- but they
simply don't have anywhere near the $250,000 Mt Sinai requested. It may
never have occurred to them the bill would be so overwhelming. They may
have done their own medline researchs and spoke with professionals and saw
that Mt Sinai in NYC has wonderful pediatric cancer facilities. Unable to
secure a medical contact through their own physician, they came in
desperation to Mt Sinai themselves. Without a clinic appointment or
admitting physician, they were directed to the emergency department so
their sick child could be assessed immediately.
Or lets say they're streetwise and here to play the press and obtain care
they knew on the plane they couldn't otherwise afford. They already knew
without $250,000 in hand a direct referral might refuse them even before
they left the country -- and then where would their daughter be? Maybe
they did further research and discovered there are ways to 'milk' the
American public to cover their child's medical bill, but they'd have to
play up the "desperation angle": go straight from the plane to the ED,
look forlorn and confused into the camera with tears in their silently
pleading eyes, etc... Can any of us blame parents for doing all they can --
including humilitating themselves on TV, fanagling in a foreign country,
begging, and even stealing -- for someone to save a life of a loved one
they themselves cannot afford to save?
(For me it's not a matter of condoning their behavior as an isolated event
so much as putting it in context. I don't know enough about their
background one way or the other to judge, but unless they took their
Bolivian millions out of the bank and hid it in Swiss accounts prior to
hoping on the plane for America, what it is they are doing we're so bent
on criticizing? It's OUR responsibility as a nation to create a health
care system appropriately responsive to the needs of our citizenry, and
the world at large -- if we fail, then it's the same as inviting others to
discover our institutional weaknesses and use them to their advantage when
life-and-death are at stake; we leave them no real alternative. I don't
expect this Bolivian family to be concerned about how their behavior
affects the great American unwashed. In the end, any other concern or
action -- other than what they've done -- ends up with a dead daughter.)
And why are we so cynical towards those millionaires helping another out
in front of the cameras? Let Marlo Thomas feel good about what she and St
Jude's are doing, let her bask in the public's glow of her humanitarian
act -- it's legions more than any of us sitting on our tushies are doing.
In her mind it may be 'free' publicity for her hospital or an act in her
father's memory. And even if it is for her -- must everyone be a 100%
saint lest they be fatally criticized for whatever good they do? It may
not be fair that she responds to publicity and not the great American
unwashed, but that's not her fault any more than it's the Bolivian
family's fault -- it's our fault, for making this media circus the only
practical way philanthropists and the needy can meet. (Here's a real
cynical thought: we do it this way deliberately, because it entertains us
to watch people in pain while those Real Americans (just like us, if we
had millions too!) come to the rescue...)
My second point: unless Mt Sinai or St Jude's plans on transfusing her
with diamonds, what in her care is costing so much money? What kind of
health care system have we here that the cost to save a life is so outside
the realm of fair trade? We laugh at $18 aspirin bills our hospitalized
patients show us, and explain it away as including the hidden cost of
everything in our medical system that doesn't get paid for -- presumeably,
the $250,000 medical care from uninsured children with cancer who we
humanely treat. But then why is THEIR bill $250,000 when the actual cost
to the hospital is probably one-tenth? Was it politics or greed or is
there another reason why Mt. Sinai didn't quietly charge the parents what
the care is actually costing the hospital and work out a schedule of
family payment or, should even that be impossible, with their government or
with Marlo Thomas for the actual cost and not the 'billable' cost.
My answers to your questions are as follows:
I don't favor national health care in this country -- I don't think we
have the sociology to make it work, and I think it goes against our
natural strengths. America seems to be at its best when government and
private resources are offered together, where there are many options
amongst which to choose.
Ernest Benjamin:
I think it is important to differentiate several different components
to this problem:
I agree that, as a nation, we cannot take upon ourselves to provide
free care for every third world citizen that needs help. At the same
time, we should acknowledge our share of responsibility in their
desperate conditions, and try to obtain that our policy makers adopt a
different attitude toward the citizen of these countries. If we
continue propping up the like of Mobutu in Zaire despite the reported
10 billion dollars that he has accumulated while his country sinks so
desperately, I would not find it surprising if, next month, the father
of another 7 year old little girl smuggles her into this country in a
desperate attempts to save her life.
Vlad Kvetan:
Consider:
Mike Rie:
Thanks to everyone who has responded to the Mount Sinai Hospital case thread. How you approach the subject depends on your perspective. To Ganesh out there in England, I personnaly cannot as an opinion leader in medicine hold to the Os trich with head bur
ied in sand view of our collective duties to the societies we serve. I hope one day you will consider reading The Nazi Doctors and the Nuremberg Code by George Annas and Michael Grodin (Oxford Univ Press). The Neville Chamberlin approach won't do it .
Granted the circumstances of our time are different, but Buchman and Crippen come closer to my view which is protection of the commons and a sense of which community ought I to owe my Hippocratic allegience to. Yes, it is hard for you and Midnight Marge w
ho look at this through the narrow prism of the individual case to see how that view is impelling us to be bastard and corrupting servants of the art of medicine. Burrows sees it but I think there is still a higher plane of questioning that we have not
as yet explored.
The Mount Sinai Hospital took an addmittedly unpopular position which I believe may be based on an older Jewish moral Talmudic writing called the Rodef passage. In the Jewish faith the principle of rescue comes from the words "you shall not stand idly by
the blood of your Neighbor. But then this commandment to spend resources is tempered by a second passage that deals with the ransoming of community members taken hostage by enemies: "Captives should not be redeemed for more than their value, to prevent
abuses".
The question was raised:Does this prevention of abuses relate to the burden which may be imposed upon the community or to the possibility that the activities of the bandits may be stimulated? Come and hear:Levi b.Draga ransomed his daughter for 13000 dena
ri of gold. Said Abaye:But are you sure he acted with the consent of the sages?Perhaphs he acted against the will of the sages."
In Christian faiths there is a schism between mainstream sects and the Mennonite sect which may be the only Christian sect to have put a monetary religious priority in saving the community over the individual. The Mennonites regard Christins charity princ
iples of the Roman and other sects to represent an unqualified commandment to commit robbery upon the commons. Simply stated, these particular non secular values are woven sublimminally into much of the way many of our societies in the last 500 years have
chosen to forget these hauntingly painful teachings.
I believe that resouce allocation issues as represented by this case will force the modern day theologic leaders to face up to communal autodestruction by narcissitic individual autonomy based values trumping everything. This should not be confused with s
trict egalitarian views of resource distribution or strict utilitarian analysis as suggested by
Buchman. We shall discover in due course "The Gospel of Inequality" in medicine and an old creed of medicine shall emerge differently expressed in different cultures.
Ganesh Suntharalingam:
To Mike Rie: You may be an opinion former in medicine, but this is a political issue not a medical one. Some time ago I tried to argue that bouncing people out of ITU
was hard to justify as we are to some extent committed to those already there,
but Dr. McKeown and others pointed out that we are effectively doctors for the
entire hospital population and must consider everyone evenly. In fact I now
accept this point; and it seems to me that you are extending it further to say
that we are medically responsible for entire countries and should stick our oar
into every decision related to hospital usage.
This is internally consistent and logical enough in its own way, but I think
there is a point of scale where the proverbial diminishing return diminishes
to near zero. I think the role of an intensivist in deciding national medical
economic policy is limited. There comes a point when the ostrich should
realise that it isn't an agronomist and that it could spend its time more
profitably by just getting on with being an ostrich rather than trying to work
out optimum ranch sizes and grass yields.
As for Chamberlain: he was in charge of directing national policy, and muffed
his job. Nobody is going to accuse you of muffing your job, and your
responsibilities, if you get on with running ITU (if that's what you do)
rather than going on TV to argue against treating people. Other people can do
that perfectly well; I just don't think it's a job for doctors. This is, of course, pure personal prejudice.
Thought for the day: didn't the Nazi doctors think they were simply fulfilling
their duties and loyalties to 'their' society ? If they'd taken the despicably
narrow-minded attitude that they'd simply do the best for every individual
patient they came across and leave non-medical factors (such as Jewishness or
Bolivianity [*]) to others to worry about, would they have done what they did?
Marjorie lazoff:
Regarding Mark Wedel's giving us the California equivalent of the 30% live birth rate for undocumented aliens, how do you explain the declining care and health status in most other states, the impossible situation hospitals like Mt Sinai find themselves i
n --- places where there isn't a 30% illegal alien birth rate and where there aren't pressing issues about proposition 187?
I see the ongoing health care needs of illegal aliens living in the US as
different from that of visa-holding families in search of specific
life-saving health care; I'm not grouping all non-citizens together,
since I think we can set up different solutions for each of their health
care needs.
I agree with those here who lament over the abuses causes by our
(ineffective) immigration process and of our (ineffective)
welfare/education/health care policies. As I understand it, if we plan to
change the latter without the former we ought to expect a social price:
increased crime, increase spread of communicable disease, deliberate
increased death -- all of which will affect Americans and arguably cost us
money in the long run. So it would seem the answer is not in witholding
care but in tightening up immigration policy, but doing so has its own
sacrifices: we'd losing a large 'slave labor' group upon which many
industries in the southern states depend, not to mention the entire
'illegal alien' cottage industry within which large numbers of now-legal
aliens and professional Americans earn their livelihood.
I don't see easy financial solutions to the care and feeding of illegal
aliens, given this symbiosis. But to visa-holding visitors seeking medical cures, I think the abuses are
more easily tolerated -- and as others have noted, their needs more easily
dismissed; there is no financial or social benefit to our helping such
visitors-in-need like the imperfect symbiosis in our helping illegal
aliens. While it doesn't work for illegal aliens, as someone here
mentioned, for the visa visitor the American people can 'go through the
motions' and leave ourselves looking wonderful without it costing us
anything for our efforts. Americans can even feel good they tried to help
the visitor, and blame someone else for not having 'come through' like
they should have.
Everyone except for physicians, that is, who by the nature of their
profession cannot share this 'turf the buck' luxury with the rest of
America. Physicians alone know what's really going on: we as a profession
allowed a patient we COULD have healed to die SOLELY because they couldn't
afford the bill. This stands no matter how we rationalize it away, how far
we distance ourselves from the patient (by emphazing their nationality,
for example), what 'greater good' logic we place in the equation, how
manipulative we believe the patient to be and how impotent we feel in the
situation... A senseless loss of a human life which our hands could have
prevented (were it not preoccupied, or forced to be preoccupied, with
holding an American dollar instead...) MUST disguist any physician's --
yes, even Dr Rie's -- soul.
I wonder if that's the dissonance many here feel regarding Dr. Rie's
comments: he advocacy of not treating non-Americans is spoken from a
rational American's perspective, a medical administrator's perspective, a
politician's perspective -- but he's so clearly not speaking from the part
of himself that's a physician to his patients. For all his touchy-feely
sniperings, Dr. Rie would never let a patient of his die because the
patient couldn't pay his bill.
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