Miscellania in tres partes

Sep 20 2010 Published by under Medical ethics, Medicine

First, a big "Willkommen" to my new German readers.  Apparently my Pope post was picked up by a German blog, and some of those folks have been nice enough to come by and leave some comments.  I often wonder if the war created a clearer message for the German post-war generation than it did for others.  Even among Americans who have heard of the Holocaust, few seem to understand its historical context.

Next, go get a cup of coffee and read today's post at Respectful Insolence. It addresses questions raised in a New York Times article last weekend, important questions about research ethics and how they mesh with the discovery of new, promising chemotherapy drugs.

Finally, there is a horrid little letter circulating on facebook.  According to Snopes, it was published as a letter to the editor in a Mississippi newspaper last year.  I present it here as further evidence that a certain subset of Americans are immoral, clueless, shitbags (Hey, Deutschlanders, check this out.)

Why Pay for the Care of the Careless?

During my last shift in the ER, I had the pleasure of evaluating a
patient with a shiny new gold tooth, multiple elaborate tattoos and a
new cellular telephone equipped with her favorite R&B tune for a

Glancing over the chart, one could not help noticing her payer
status: Medicaid.

She smokes a costly pack of cigarettes every day and, somehow, still
has money to buy beer.

And our president expects me to pay for this woman’s health care?

Our nation’s health care crisis is not a shortage of quality hospitals,
doctors or nurses. It is a crisis of culture — a culture in which it is
perfectly acceptable to spend money on vices while refusing to take
care of one’s self or, heaven forbid, purchase health insurance.

Life is really not that hard. Most of us reap what we sow.


First, let's be clear who he is writing about.  This doctor uses very clear dog whistles that imply that the patient is African American (gold tooth, R&B ring tone).  This immediately sets a specific tone: the patient is poor, Black, and therefore beneath being treated with basic human dignity.

But even pretending for a moment that this isn't an obvious racist screed, there are even more flaws with Dr. Jones's "analysis". This doctor objects to the government spending money on health care for someone with "bad habits" and who isn't, in the doctor's estimation, sufficiently frugal.

He uses this example to show how Medicaid (government medical assistance for the poor) is a waste of resources since poor (and presumably Black) people don't conform to a certain set of behavioral standards.  (Medicaid, by the way, primarily targets children and their parents, rather than childless adults.)

Physicians are, of course entitled to their own political beliefs, so let's assume that the obvious tone of disdain for his patient was absent from the letter.  The question then becomes,  should public assistance (for health care, food stamps, etc.) be tied to specific behavioral goals?  If so, why?  And how?

It is impossible to set behavioral goals for public assistance.  Do we really want to be in a position to punish people for being dependent on nicotine?  Do we want a panel to judge if a particular purchase made by a welfare recipient was non-frugal enough to cut off their assistance check?

Some people would like to do just that, or more likely, they would like to eliminate any form of government assistance.  This is a view born out of an inability to empathize in any way with the suffering of others.  This and his punitive desires  are clear in his letter when he suggests that a poor person purchase insurance, and when he states that life isn't hard and we should reap what we sow.

This point of view is objectionable in the way it dehumanizes the poor, the way it demands certain behaviors from the poor in exchange for basic human services.  As the letter shows, certain behaviors---those associated with minorities---are particularly despised.

While Dr. Jones's political views reveal him to be a  crappy human being, they also show him to be lacking in the basic empathy necessary to be a good doctor.  "Why pay for the care of the careless?"  Because we are "careless" from time to time, and because it's the right thing to do.

As physicians, we are daily in grave danger of rendering unhelpful judgments on our patients based on behaviors which we consider "bad". It is our calling, our responsibility, not to render judgment but to help them change in whatever way they can.

As physicians we must continually ask ourselves, "is what I am doing or planning in the best interest of this patient, or am I doing it more to please myself?"

In Jones's case, the answer is obvious.

27 responses so far

  • k8 says:

    I worked for the church for many years. We were often the target of people down on their luck who wanted money. For whatever it was they wanted or needed it for. Several of our parishioners would complain about the slush fund created for this reason and said that "those people" were obvious drunks or addicts and probably "already abused the system."


    So what if they were?

    At the end of the day, they are still hungry. They've got kids are home. Are you going to feed them? Maybe not all the money we gave out was going to be used for that specific purpose, but ultimately, that's the question you're asking. If your simple humanity is not enough to help, I don't know what is.

  • Kevin says:

    Hey Pal, just a heads up, your link for "respectful insolence" also links to your Yom Kippur post.

  • makarios says:

    With these last three posts you are really on a roll. Thanks .

  • Thank you for this. I linked to this post on my facebook, sorry if I send any crazies your way.

  • Dr. W. says:

    Wow. I can't believe Starner's letter has circulated like this. We took our pre-med classes together, and his beliefs haven't evolved much in the past 12 years. They in fact seem to have stewed in a blend of self-righteous fundamentalism, sleep debt from a few too many 80-hour weeks, and a delusional understanding of humanity born in the bowels of a Memphis emergency room. When I emailed him to find out more, all he could really offer was that "it's a lot more complicated" where he is. The scary thing is that some of my classmates who called him crazy back then are a little sympathetic now.

  • JM_Shep says:

    It is very clear that this guy has no idea what its like to not be male, white, and christian. I recognize the fact that I was very lucky to be raised in an area where most of the people around me were like me. He doesn't, and probably never will.

    I just don't understand how to make people like this realize not everyone had the opportunities they did. Until they spend some time as a minority, I don't think they will.

  • John H. says:

    Wow. Would that everyone's wisdom and judgment were as pure and directed as the "good" doctor's. Human nature is what it is. The best we can do is keep trying.

    I would never eliminate government assistance for the poor and the needy. For every drug addict receiving government benefits, there has to be a dozen families also helped. And besides, who's to say the "drug addict" won't eventually get off the stuff and become a clean, tax-paying (i.e., productive) member of society? I'm not naming names, but not every dollar is wasted. To your point: where do we draw the line? And how?

  • theshortearedowl says:

    Thank you for this. I saw the letter on Facebook, posted by a (now) doctor I knew when s/he was a student. I almost made some sarcastic comment, but just couldn't face the offended incomprehension that would follow.

    Incidentally, I didn't pick up on the racist bit - the gold tooth, tattoos, RnB ringtone perfectly describes a lot of the poor (and not so poor) white folk in my neck of the woods. So I say the post is offensive even without its racist connotations.

  • Daniel J. Andrews says:

    It seems obvious he's using this person to justify his political ideological beliefs rather than deriving his political ideological beliefs from this person. He doesn't think health care should be extended to everyone. If you showed him a very frugal person with no vices who couldn't afford health care insurance, then he'd find another reason why this person doesn't deserve it (e.g. she made bad life choices earlier when she was younger).

    Or show him someone who was married to a scam artist, or someone who, like a good friend of mine, was married to someone who became addicted to pain killers, and managed to run her into deep debt before she kicked him out. Now a single mom raising two teenagers and still saddled with a load of debt (which he can't help repay as he's on disability and can't afford it).

    She has no vices, she makes her own soups, stews, from dried lentils, beans, she bikes or rollerblades to work so she doesn't spend money on gas. I suppose he would say she shouldn't have gotten married at 18 so it's her own fault. Or that she could be even more frugal--say, quit drinking tea--she uses and reuses one tea bag per day.

    In fact, for more than half of my adult life I wouldn't have been able to afford health care as I was competing for job contracts against people more qualified than me so unemployment was the norm. Now I'm the qualified one and I'm seeing lots of young people still struggling to get jobs, or just leaving the biology field altogether for something more lucrative and stable. Suppose we should be punished too for making bad choices about our career field and coming out of school saddled with a load of debt and finding no jobs so we sink even more into debt.

    I just have no patience for people like this doctor, and I'd have to say he sounds like a doctor in name only. I'd like him to live for a couple of years at or below the poverty level, or have his insurance company decide they won't cover him when he gets sick. Might knock some empathy into him. Btw--what the hell is wrong with your system when insurance companies can revoke your coverage??!!--Does that happen with house and car insurance--Do you pay to be covered against auto accident only to have the company refuse to pay because you had, like, an auto accident? Fire insurance won't pay because you had a fire?

    Incidentally, why is it that all those who are most vocal against a universal health care system are all privileged middle-to-upper class who already have health care?

    As another aside I just read The Poisoner's Handbook, and during the Prohibition era it seems the government was equally unsympathetic as it was looking for more and more poisons to put into alcohol so people wouldn't be able to purify it as easily for drinking. Again it was the poor who were dying in large numbers from drinking poisoned alcohol, but the government response was "they shouldn't be drinking in the first place", and looked for more poisons to use. This doctor would have been right at home in that era.

    • JustaTech says:

      Dan: At least as of this coming Thursday (the 23rd) your health insurance won't be allowed to drop you if you get sick. Yay health care reform!

      Sometimes the deeply bitter, cynical, angry part of me says that we'd have so much more money if we just shot all the sick and old people. But that's the horrible part of me, and I don't let it out. But some days I feel like there are people out in public life who think that is a perfectly reasonable solution. And that wraps right back to Pal's last post.

      • EK says:

        re: the 1st paragraph - I didn't know that.. Yay, indeed :).

        being a 20-something "sick" person and walking pharmacy frequently subjected to expensive diagnostic tests, who can likely look forward to being sick for the rest of her life (multiple heritable conditions, though I work); as well as frequently being perceived as a "difficult" patient/someone who isn't worth either the time or the effort to care for, etc. (I'm on the autistic spectrum); I feel oddly compelled to thank you for both recognizing this and not feeling justified in taking it out on people like me (and we do notice when it happens, it always strikes me as incredible when it's assumed that we're entirely oblivious to the animosity, or couldn't care less).

  • Silver says:

    It must be difficult for Dr. R.S. Jones, working in a busy ED, only feeling morally comfortable caring for the victims of lightning strikes or the occasional meteorite impact and people suffering non-vaccine preventable illnesses. That would be a very stressful job indeed.

    Thanks for this. I work with these patients. All day.

  • OleanderTea says:

    Hm, is the doc's Vitals page reviews being, um, updated?

    I see quite a bit of recent activity.

  • Samantha says:

    I work for a company that works with hospitals all over the country, connecting staff and LEPs with interpreters. I have always been willing to give staff I talk to the benefit of the doubt - I don't expect you to be extremely pleasant when you've got someone who can't understand you in a panic in front of you because they're hurt and don't know what's going on. But I never cease to be amazed with the routine clinic visits, when there's outright racism and bigotry as the patient is sitting in front of them. I don't understand how people can get into helping professions - careers that involve getting down and dirty with the best and worst of us - with attitudes of superiority and coldness.

    Is the prestige and money really that good to have a job where you hate so many of your clients?

  • [...] I thought a bit more about the doctor who wrote the letter to the editor we discussed yesterday, I wondered how two similarly-trained doctors (he and I) could come to such different conclusions [...]

  • Orac says:

    Incidentally, why is it that all those who are most vocal against a universal health care system are all privileged middle-to-upper class who already have health care?

    It's obvious. In fact, they will often even tell you: They fear that their health insurance will become more expensive and resent paying for others whom they view as deadbeats.

    • daedalus2u says:

      It is ironic, but the reason health insurance is so expensive in the US is not because of care for deadbeats, but because of the non-health care costs that insurance companies add to health insurance premiums, insurance company profit is one, but the biggie is figuring out which of their policy holders might need health care and getting rid of them any way they can.

      I think the physiology that induces the kind of mindset expressed by the Dr is analogous to Stockholm Syndrome. He can't fight against the insurance companies that pay his bills, or the system that he is a part of, so he displaces all his anger on people at the bottom of the social hierarchy. That is the whole purpose of a social hierarchy, to have people at the bottom that one can feel and act superior to.

    • James Sweet says:

      And yet, as a "privileged middle-to-upper class person who already has health care", I can tell you that my health insurance is getting shittier by the year. I work at a major multi-national company too. And seriously, year after year after year the benefits steadily get worse.

      I want a public option purely out of self-interest, because I seriously suspect it might be better than what my employer offers right now. That would not have been the case a few years ago, but I'm not so sure now.

  • Diane-with-one-N says:

    As a nursing student, I am already shocked by the extremely prevalent judgemental attitude towards people with obesity-related problems, particularly diabetes. There seems to be a real undercurrent that these people "deserve" to be sick because they have made such poor lifestyle choices. That the illness is punishment, and should be treated as such.

    This post adds to my belief that judging our patients doesn't help them, and strengthens my resolve to not become one of those people.

  • Vicki says:

    Thank you, Diane.

    It's bad enough when medical professionals make it clear they don't respect their obese patients when the medical issue is arguably related to obesity: for example, diabetes. What scares me is the number of my friends who have reported scorn and neglect when they came in with completely unrelated medical issues: the doctor who wouldn't help a woman with a badly sprained ankle, instead lecturing her on losing weight.

    I don't think that's primarily because the medical people think there is a causal connection between a broken ankle and fat: it's because they share the societal prejudice against fat people, and especially against fat women. Given the opportunity—a patient who is sick or in pain and needs something from them, and can't just walk out on the tirade—too many doctors and nurses will let that prejudice out. Many of those same professionals will neglect and undertreat their non-white patients, though as far as I know they don't order black men to become white before they can have treatment for high blood pressure.

    Ethics doesn't require a person to like all their patients, but to provide appropriate treatment even when they don't. (Similarly, for a layperson, "s/he's a lazy slob" doesn't justify unethical behavior in other areas: but that, too, is common.)

  • Jurjen S. says:

    It's worth remarking that a large part of the cost of that "costly pack of cigarettes" consists of taxes; taxes which, one would hope, are being funnelled back to pay for health care expenses (and if they aren't, why not?). It also deserves notice that alcohol and tobacco are among the few luxuries that poor people can actually manage to pay for. They can't raise enough money at one time to take a vacation or engage in some hobby like, say, kayaking or skiing.

    Moreover, it strikes me that Dr. Jones doesn't have a very good idea of how insurance notionally works. The idea is, after all, that all the company's clients pay a premium, and the insurance company uses the money from the premiums to pay the medical bills of the comparatively few people who require expensive medical treatment. Essentially, if you have health insurance but are currently not receiving medical treatment, you are in effect paying for someone else's health care. Just like they're going to wind up paying for yours if you require medical treatment at a time they don't.

  • muteKi says:

    As the original article suggested, the only thing I can think about in this matter is the question of driving uninsured -- why isn't it a hot-button issue? I mean, if those schmucks getting into all those car accidents would just pay attention to the road instead of the car stereo, I wouldn't have to subsidize their repairs...

  • VolcanoMan says:

    It always blows me away that there is a not-so-insignificant proportion of people in the great "Christian" nation of the US of A that have an astoundingly profound lack of empathy for their fellow humans. Where is the cognitive dissonance? Are you only supposed to love and help and be Jesus-like to people who are like you? Not to mention the fact that these people almost exclusively fall into the "patriotic" self-categorization, and yet they conveniently forget about those inalienable rights of life, liberty and the pursuit of happiness. Does not a right to life imply a right to good health care?

    Perhaps some of the people expressing these views now are just taking out their frustration at the current economic situation on those who are least at fault, but there is a core group of people who actually don't see the connection between other people and themselves, who don't see that the dual factors of where and to whom you are born, in our world today, have the greatest impact on who you will become. There are people like this here too (in Canada), but the mythology of the self-made man is in an American's cultural DNA I think...so many people believe it.

  • Darren says:

    I also cannot believe this Doc's disdain for his patient.

    1. Gold tooth - this is a dental crown, often done as porcelain-fused to metal on a front tooth for esthetic reasons, but can be done in full gold (an older technique) if the patient insists. It actually required less reduction of sound tooth structure, and costs the same or slightly less. The overwhelming majority of time it's done as tertiary care for a fractured tooth (trauma) or dental caries (bacteria-mediated infectious disease). Condemning his patient for this is incredibly ignorant and borderline stupid. Perhaps as an ER doc he'd prefer her to present with an acute facial abscess secondary to untreated dental disease?

    2. Cell phone - depending on her living circumstances, there's a very good chance that a cell phone is cheaper than a landline. It certainly is in my case, especially since I spend a good deal of time away from home. And people get new phones for free or almost free all the time as enticements to stay with the same service provider.

    3. Ringtone - costs what, a dollar? How much healthcare will that buy?

    4. Multiple elaborate tattoos - probably done over the course of many years, and the cost of health insurance over that time period likely dwarfed the costs of tattoos by a couple orders of magnitude.

    Even if the costs of obtaining these characteristics were greater than that of purchasing quality health insurance - a huge, gigantic "if" - this guy is clearly not thinking in terms of his patient's best interest.