How can we best care for persons who are medically indigent in a world of limited resources?

• Author: Mosley, Mark L.

The doctor was closing his bag now. He said, "When do you think

you can pay this bill?" He said it even kindly. "When I have sold my

pearl I will pay you," Kino said. "You have a pearl? A good pearl?"

the doctor asked with interest.

The framing of the question determines the architecture of its answer. Perhaps this is why medical ethicists derive extensive verbal mileage from the dictum "We must first learn to ask the right questions." Even then, we can be too hasty. We must first recognize the "wrongness" of the old questions. We must learn to disassemble "rotten" presuppositions to prevent the revamping of old questions behind facades of newly constructed terminologies.

The title for this medical students' and residents' ethics essay contest, "How Can We Best Care for Persons Who Are Medically Indigent in a World of Limited Resources?" provides the structure from which the author will begin to build new answers. First, the "wrongness" of the title question will be critically analyzed. Second, a new question, possibly a "right" one, will be suggested. Finally, some creative answers will be discussed.

The "Wrongness" of the Question

The question "How can we best care for persons who are medically indigent in a world of limited resources?" has four presuppositions as its cornerstones: (1) We (American physicians) are expected to intervene; (2) a "best" care approach exists for persons who are medically indigent; (3) persons who are medically indigent would be better off if we did intervene; and (4) limited resources in this world are a primary contributing factor to medical indigence. These premises are faulty and disable us from raising new questions, if not "right" ones.

American Physicians Are Expected to Intervene

"There is no place in the world," not even third-world countries, "where people are more dependent on doctors and medicines and hospitals for their health" than in the United States.(1) Meanwhile, "seven of the ten leading causes of death in the U.S. are related to a person's lifestyle."(2) The "pearl" of health is valued without the discipline required to produce it. In essence, Americans want to feel better without having to act better. "As control over the behavior of a person has shifted from family and church to physician, |be good' has shifted to |take your medication.'"(3) Idolatry of wellness has become religion with hospitals and clinics as its mecca and pharmaceuticals as its sacraments. Physicians, now called "health providers," are expected to make patients responsible for what patients have not been responsible for themselves (e.g., stopping smoking, decreasing cholesterol, having safer sex, losing weight, learning to relax, decreasing alcohol intake, and increasing exercise). Of course, this insurmountable task must be done without making anyone feel guilty--i.e., "Doctors should not play God!" They should just be valueless priests who listen to confessions and absolve sins with a wave of prescriptions.

With media-sized expectations, Americans congregate to their physicians and to their government leaders, not only desiring to be made healthy, but demanding health as a guaranteed "right." Americans have erroneously equated the concept of health with the practice of medicine.

Medicine is a short-term intervention, or a monitored nonintervention, to ward off acute illness and impending death. Medicine is not a guide for health any more than criminal law is a guide for virtuous behavior. Both professions are designed to remedy intolerable aberrations, social ones for law and individual physical and mental ones for medicine. Neither has much to say to those living "well" for the moment; neither points toward optimal or virtuous behaviors. We usually don't encounter the medical or justice systems unless something is "wrong."

Health, as opposed to medicine, is a condition of living belonging to an individual and related to culture-bound values. Health, let alone information about health, is rarely delivered by doctors--it is an individual's intrinsic quality communicated by family, friends, television, and the community of one's culture. One person has defined health as a "man's stewardship of himself."(4) Health is not a right that the medical profession or government can promise. To claim "that there is an obligation upon society to provide health for its citizens not only is logically absurd and morally indefensible, but is also medically impossible."(5)

Without question physicians in the United States are quite able to practice medicine, with a world-renowned information system, unsurpassed technology, and wide-ranging specialty services, representing a sizable portion of the gross national product (GNP). However, an overall improvement in health in the United States is questionable. Denis Burkitt, M.D. (for whom Burkitt's lymphoma is named), has suggested:

[E]ven on a purely scientific level we have probably grossly

overestimated the achievements of medical science, yet when one

considers man in his true proportions, it is humbling to realize (and

more so to acknowledge) how relatively little we have benefited

many of our patients.(6)

If this is true, one can conclude from this enigma that better medicine (increased information, technology, services, and financing) does not correlate well with Americans living healthier lives. Furthermore, while physicians may be excellent providers of medicine, they have not been and are not designed to be deliverers of health.

A "Best" Approach Exists for Persons Who Are Indigent

We who doctor, educate, and write articles about persons who are poor are already at a cultural disadvantage in that we are not poor. We must be cautious in immediately nodding our approval for programs designed to improve health among the poor as if we easily understand who "the poor" are.

In rural areas "the poor" are predominantly white and live in male-dominated households without government assistance.(7) In the large inner cities, they are predominantly black and Hispanic. "The poor" are a heterogenous group including a disproportionate number of persons who are physically disabled(8) and persons who are mentally disabled (one-third to one-half of all the homeless).(9) An interplay of behaviors among some of the poor include drug abuse, domestic violence, sex peddling, alcoholism, and loitering. There are also the underemployed, the immigrant workers, runaway children, the temporarily homeless, and the unemployed. Although the majority of the media and scientific literature focus on the large inner city poor, with particular emphasis on the homeless and single black female heads of households, there are large numbers of poor people on farms, in trailer parks, on beaches, in medium-sized cities and towns, in fields picking our fruit, in retirement dwellings, and in restaurants cleaning our dishes. With the geographic, ethnic, and cultural diversity of poor persons, we should reason that a single best solution or standardized program designed to cover the majority of these highly diverse cultures is inefficient at best.

One example is the "War on Poverty" of the 1960s, implemented through Medicare and Medicaid. This has become a type of medical Vietnam in which the government took control of the poor in an attempt to bring peace to a "war" that was essentially a cultural conflict. Now we are captives of our past. In expanding social and medical territories of government health teams, often we "erode people's choices about how to lead a healthy life."(10)

All diseases have a lot to do with what's going on in people's lives. And people's lives are shaped by their unique personalities, environments, and cultures. To treat disease and encourage health with a method transplanted from a different subculture is futile. And worse still is to standardize this "best" approach to all of the different communities of poverty. While some government programs like WIC (Women, Infants, and Children), Head Start, and Meals-on-Wheels appear to be working and should be strengthened, on the whole, the government is a poor provider of medical care and health values from a cultural, economic, and political point of view.

The government is but a reflection of the American public's own short-winded, best-shot, "put-it-in-a-package-and-sell-it" philosophy. Programs like the community psychiatry movement and community action agencies are reported to have failed based on opposition by the community.(11) This is not a criticism of the motive of government, health care facilities, religious organizations, and philanthropic associations; it is a criticism of their methods. If we go into a community with a predesigned curriculum, we are doomed to failure--people learn best when they discover for themselves(12) their health values, their day to day needs, and the priority of those values and needs. A Hispanic pregnant teenager in south side Chicago will have a radically different understanding, communication, priority, and approach to her health and medical needs than will an older, disabled, married, white farmer in rural Oklahoma. Using the same "best" approach to both of them is not reasonable.

Some groups have attempted to bridge the gap in diversity of medical needs with a "health team" approach. "It is naive to bring together a highly diverse group of [outside] people and expect that, by calling them a team, they will in fact behave like a team. It is ironic indeed to realize that a football team spends forty hours a week practicing teamwork for the two hours on Sunday afternoon . . . . [While] teams in health organizations seldom spend two hours per year practicing when their ability to function as a team counts forty hours per week."(13)

Although unsatisfying to our American short-term, goal-oriented, desire-to-structure-everything psyche, there is no single best program or standard best plan to interface with persons who...