Choices and Health

Choice about medical care is a privilege for those with agency conferred to them by economic standing.

A few weeks ago, 2 very different meetings confirmed this for me. During a lunch meeting, AMSA (American Medical Student Association) gave a presentation on international rotations. Our Assistant Dean of Medical Education, who has practiced medicine in many different places around the globe, gave the talk and showed us many graphic pictures of typical images that we would encounter on a rotation in Kenya. In these photos, folks lined the streets in front of the clinic from dawn til dusk and came in with open wounds, huge goiters, malaria, AIDS, and many other 'preventable/treatable' diseases. These folks had walked for many miles to come to the clinic. They would then wait for hours, be evaluated, and before returning to the long road home, were either given a prescription for which they probably did not have enough money to fill or given free medication that would not be enough to affectively treat their illness to full recovery. Image after imaged passed across the screen. Photos of starving babies and huge skin ulcers were the most recurrent. I turned my gaze away many times. I left the meeting with mixed feeling. On one hand, I was sad and outraged. On the other, I now know how I wish to spend at least one month of my intern years!

The following days, we had our bi-monthly ethics seminar and subsequent group assignment, where we work together to consider the ethical components of a particular case. This semester our ethics course is entitled "Medicine in Spiritual Perspective." Our lovely ethics professor gave a brilliant talk over how spirituality and religious practices inform our rituals surrounding birth and death, and in between, our understanding and interactions with healthcare. We were then given a case in which the patient, a Jehovah's Witness, was in need of a blood transfusion yet her religious beliefs did not permit the 'consumption of blood.' Together, we attempted to understand how her faith functions in response to health. We did this by considered the following questions:

“Do you have spiritual or religious beliefs or faith and practice that may be of help in your health recovery?” “How are these important to you?”
"Do you hold these beliefs or practice in this way alone; or are you part of a group or religious community who share your faith and practice?”
“How can we address your faith and practice to help you make best use of them in your recovery of health?”

We decided that to best manage this patient’s care, were would need to seek alternative treatments to a blood transfusion. There are few alternatives that are truly viable options, but to be considerate of her beliefs and practices, it is imperative, as her physicians, to pursue these options.

The entire group exercise was incredibly painful for me. I am usually vocal in these sessions, but that afternoon I sat quietly with my arms crossed, sinking further and further into my chair, drowning in thoughts that made me cringe. With the images of Africa in the back of my mind, I simply wanted to say to this patient, like a parent to a non-compliant child at the dinner table, “Dying kids in Africa, Iraq, South America, or South Dallas would walk 40 miles one way, in the heat, without food or water to have that blood.” Of course, I would never say this, and under normal circumstances, even when I disagree with folks, I deeply respect anyone who makes difficult decisions based on religious conviction. But, that afternoon, the whole situation seemed ludicrous to me.

The band U2 has a great song called Crumbs from Your Table. It addresses the incongruence between our spiritual language and our everyday ‘praxis’ of these words, especially in relationship to global poverty. Here are a few of the most commanding words:

Where you live should not decide
Whether you live or whether you die
Three to a bed,
Sister Ann, she said
Dignity passes by

And you speak of signs and wonders
But I need something other
I would believe if I was able
I’m waiting on the crumbs from your table.

Poverty robs individuals from injecting their faith practices and ethics into the world of medicine. They are silenced by their desperate need from speaking at the ethics table. It seems that only those who have the luxury of understanding the mechanics of stem cell research or paying for physician-assisted suicide have reserved seats.

These are important issues indeed; however, in some respects, I think that are simply the ones we engage because they are sexy and ‘cutting-edge’ ethically. But when are we going to wake up to the ethical issue with the greatest determinacy on health outcomes? (Economic standing) When will we address the brokenness and questionable ethics of our national healthcare industry, and then the huge disparities in global health? Should these be in the forefront of our conversations as future healthcare providers or should they be left to the economist? What are the real ethical issues for physicians? What do you as a once and future patient think?