Everything’s Got a Moral, If Only You Can Find It

In moments of weakness, when I should be doing something useful, I sometimes think about the logic that underlies the way medicine is organized (disorganized is probably a better word). The business—and it is a business, what with consumers, advertisements, and reimbursement rates—seems to thrive on contradictions. Consider medical care for the indigent; if you do so, you are apt to be lonely, but do it anyway. In Illinois, as in many other states, the recession has caused the state to drastically curtail the amount of money available to support health care for the poor. Consequently, many impecunious but honest citizens are denied necessary medical care. Dishonest citizens, however, appear to have an ironclad legal right to every form of medical care.

Convicts have a right to medical care, enforced by numerous court decisions, which is absolute, if you are seriously in need of medical care and are without resources, a logical step is to commit a crime. Of course, you must make sure that you get caught and that your lawyer is a complete nitwit. Otherwise, you probably will not be sent to jail. To ensure a jail sentence, you should commit a serious crime and insist on your sanity. Once you have garnered a jail sentence, the state will provide you with whatever medical care you require or think you require.

Suppose you are not a citizen but are an illegal alien. The state will assume no responsibility for your medical care even in times of plenty. In the unlikely event that you are apprehended by the immigration authorities, you may even be deported if it is politically expedient to do so. Again, however, crime pays. Get yourself into jail, observe all the mechanics mentioned above, avoid deportation, and once again the state will assume complete responsibility for your medical needs.

Not only will the state provide medical care for convicts, but inmates of penal institutions have the right to bring suit in federal court alleging that the care they receive is substandard. If they succeed in convincing the court that only one of however many charges of ill treatment they allege is correct, then the state must pay their entire legal bill. It should not be necessary to comment on how frequently the state pays for the services of a high-priced lawyer engaged by the poor but honest soul.

Leaving the dark world of incarceration behind, one can find similar contradictions in the well-lit offices of hospital administration. In an office with a potted plant or two, false ceilings, fluorescent lights, and a pleasant outside view, one is apt to find a hospital administrator who on Mondays, Wednesdays, and Fridays writes memos to the physician staff in his capacity of director of the PSRO program, asking them to justify the need for hospitalization of patients who fall under the purview of this exotic program. On Tuesdays and Thursdays (Saturdays these offices are dark), in his capacity as a high-ranking hospital administrator, he writes letters to the chiefs of services imploring them to fill the empty beds which are becoming an increasing embarrassment to our overbuilt hospitals.

In another part of the hospital sits a wise physician who bores his residents and students with daily admonitions to decrease the cost of medical care by ordering fewer
sophisticated diagnostic procedures which jack up the hospital bill. In his philosophical
ruminations, he elevates the physical examination to the level of the deity while
consigning the CT scanner to the underworld. In his private practice he orders every test available to protect himself from the omnipresent clutches of the malpractice lawyer.

In yet another office, the chief of staff imposes a set of rules governing the “do not resuscitate” order. These rules, while not understood by anybody, induce a state of near total paralysis on the part of the nursing staff which eventually is cured by resuscitating anything that remains motionless for more than five minutes. Across the street a medical ethicist writes about death with dignity, removed from the sound of breaking ribs.

Since we all want to be nice, we come up with nice rules. Since abortion is intensely controversial, it seems reasonable to permit those hospital personnel whose convictions do not permit abortion to refrain from taking part in this procedure. The logical continuation of this practice is to permit other hospital employees to opt out from these procedures which they find personally repugnant. For example, a Jehovah’s Witness who happens to be a hospital transporter should not be required to carry blood from the blood bank to the bedside. Ultimately, one can imagine Christian Scientist pharmacists and physicians who dispense no drugs and perform no surgery. Carried one step further, we arrive at the personnel department’s beau ideal: a different job description for every employee, written by each employee.

One should never forget the maxim of the great, but unknown, pre-Confucian philosopher: “The examined life is not worth living.”

Originally published:

Kurtzman NA: Everything’s Got a Moral, If Only You Can Find It. Sem Nephrol 3:167, 1983.