Should hospitals and doctors make value judgements about who deserves treatment?

I heard on NPR’s “Here and Now” (Sept 9, 2021) that Jimmy Kimmel, the late night TV host, had expressed anger and frustration with people continuing to refuse vaccination for COVID-19. He noted that many hospitals no longer have available Intensive Care (ICU) beds available, and were going to have to triage who was admitted to them. According to the host, Robin Young, Kimmel said the decision was easy: you have a heart attack, you’re in; you have COVID and didn’t get vaccinated, you’re out. (His monologue is summarized by The Hill, among other sources.) Kimmel is not the only one to express outrage at the unvaccinated -- “shock jock” Howard Stern has responded to those who would cite their freedom to not be vaccinated with “F—k their freedom; I want my freedom to live!”— and is also not the only one called for such “ICU triage”.

Daniel Wikler, a professor of medical ethics from the Harvard School of Public Health was Ms. Young’s guest, and he said that, while he understood the anger that Kimmel and others were expressing, and empathized with it, he did not believe that it was the business of doctors or hospitals to make such decisions. It was the tradition and history of medicine, he said, to treat the illness of the patient if it was treatable, not to decide that someone had done something to themselves to make them undeserving of treatment. As an example, he noted a skier who might ignore all warnings, ski down the back of the hill, and get injured. There are lots of other potential examples, and they are valid.

I agree with Dr. Wikler on both points. First, I understand and empathize with Mr. Kimmel and others who are furious that those who have refused vaccination not only threaten the health of the rest of us but also end up utilizing a huge amount of health resources and services that not only can limit access to these services for others in need, and in any case cost huge amounts in time and effort by health professionals as well as in money. But I also agree that doctors and hospitals have no business refusing to care for these people, and that a core ethical value in medical care has been to provide care, if you are able, to help the illness of the patient, not to judge whether they are worthy of care because of their previous actions. One of the most dramatic and important examples are medical facilities in war zones, which are obligated by the Geneva Convention to treat all injured on the basis of need, not which side they fought on. To treat one’s own soldiers and not injured enemy soldiers who are prisoners is a war crime.

Many of those people who have the heart attacks that Mr. Kimmel thinks should get them into the ICU smoked cigarettes, or ate a very poor diet, or did not exercise, or all of these. While I’m sure that there are some people who are judgmental and smug enough to believe that they should suffer the results of their own life decisions and not receive care, this is not the approach that doctors and hospitals take.

There are certainly many people whose illnesses are at least partly a result of other poor decisions, including use of alcohol – both heavy lifetime use and even one episode which led to the car accident that has them in the emergency room – or other drugs. In addition, while less common than from alcohol, illness and death related to illegal drugs such as opiates and opioids and stimulants is still very common; we have all heard of the “opioid epidemic”. And there are infinite possibilities for blame when you go beyond “sins of commission” – things you did that were bad for you – and enter the realm of “sins of omission” – thing that you didn’t do that are, at least in the view of the one making the judgement, would have been good for you (e.g., diet and exercise).

Back to domestic hospital use, I would like to discuss two examples from my own experience. Suicide attempts are definitely self-inflicted, but the motivation to act is often transient, and many people who attempt suicide and survive do not attempt it again. Guns are very lethal, however, with well over 90% of suicide attempts by gun being “successful”; drugs are less so. My son killed himself with a gun, but if his attempt had been with a less lethal method, I  certainly would have wanted him treated.

On our inpatient services, residents and I have cared for many people who are repeatedly admitted with the effects of their use of alcohol or other drugs. One person I remember well. Regularly admitted for the toxic effects of alcohol overdose, on treatment and release he always pledged to get treatment for his disease, most strongly motivated by caring for his daughter, but never followed through. After many admissions, some residents thought it wasteful to continue to treat him and argued against it. My position was not only was recovery a difficult process, often with many failed attempts, but that our role was to treat his medical condition and refer him for treatment for his alcoholism. We could make the judgement that he was at fault, and each of us might have our own opinion about whether he “deserved” treatment, but that was irrelevant to our obligation to take care of it. It would be a slippery slope indeed. And I would be remiss to not point out the most common reason people are “triaged” to not receive care, at least in the US, is financial: they do not have money or good insurance. That is totally immoral and unacceptable.

There are some differences with those who refused to be vaccinated against COVID or wear masks or distance, but these are variations on a theme. Yes, they put others as well as themselves and their families at risk, but so do those who drink and drive or use other drugs, or who do many other things. It is our job to take care of them to the best of our ability. To do otherwise is to risk great hypocrisy, thinking that those who do the dangerous things we ourselves do are less culpable than those who do dangerous things we do not do and decry. I call it the “Jesse Helms fallacy” after the former powerful North Carolina senator who both opposed treatment for people with HIV/AIDS, who he said were suffering God’s punishment for their homosexuality, and also smoked like a chimney and fought for the tobacco industry. When he had developed heart disease, he sought and received treatment, despite being largely personally responsible for it.

That so many are refusing vaccination and care that there are no beds in ICUs in many states (as a person from Alabama did from heart disease after being unable to get a bed in 43 hospitals in 3 states, and as is occurring across the poorly-vaccinated South) is shameful, discouraging, and incredibly dangerous. These people are misguided, stupid, and many are even evil. But we also hear of those who (because they are dying, to be sure) regret their decisions. We can feel some sense of self-righteousness when we hear about anti-vax personalities who have died. If we are in institutions where there are not enough beds and patients have to be triaged, that triage must be on the basis of their condition and our ability to help them. The social/political fight cannot be waged at the bedside of an individual patient.

As much as we might be tempted to do so.

Killing our children: Guns, mortality and morality

There is really nothing to write about at this time other than the ongoing carnage in our nation as a result of angry young men (always men!) shooting up their schools, most recently (at least at the time of this writing) with the death of 17 students and teachers at Marjory Stoneman Douglas HS in Parkland, FL. It is hard to write through the tears. This should not be going on. Many people have written pieces on the subject -- sad, or angry, or articulate, or all of these. One of the most moving appeared in the New York Times on February 18, 2018, by a man named Gregory Gibson whose son was killed in a school shooting 25 years ago. The online headline, “A message from the club no one wants to join”, is different from, and in this case is much weaker than, the print headline: “Why wasn’t my son the last victim?”

Why indeed? Twenty-five years ago. And since then, countless school shootings, and other mass murders (such as, if we needed reminders, the Las Vegas country music concert, the Pulse nightclub in Orlando and the First Baptist Church of Sutherland Springs, TX) have occurred, and every parent, every family member, wants to know why the most recent prior child to die was not the last, instead of their child. People are terrified; a friend, a rational physician, embarrassedly admits to looking online for Kevlar backpacks for his children. He does international “mission” work and is taking his 14-year old daughter to Africa; when people ask him if he is worried about her safety there, he says “no”, but he is worried about her safety attending school two miles from his home in an affluent suburban community in the US. His day job includes being a leader for the quality program in his hospital, where he searches the actual data for root and contributing causes to problems; he wonders why this country cannot do the same for gun violence. Arizona Star columnist Dave Fitzsimmons expresses similar fears for his children.

This country could, but so far it shows no sign of doing so. Gibson quotes the author Chester Himes commenting on the lynching of 14-year old Emmett Till in 1955 that “The real horror comes when your dead brain must face the fact that we as a nation don’t want it to stop.” Himes was talking about lynching, but it is clear that the same can be said today, more than 60 years later, about school shootings. We don’t want it to stop. Because, if we did, we would do something about it.

Of course, we do, most of us. Various surveys, asking the question in different ways, find different percentages, but always large majorities, of Americans want stricter gun laws, often up to 90%. Even most people who are members of the NRA and/or are registered Republicans want limitations on who can buy guns based on mental illness and other criteria (always “me, and people like me”, but not the people like you) and some kinds of guns or gun modifiers (like “bump stocks”, used by the Las Vegas shooter to turn his AR-15 semi-automatic – and by the way almost all these shootings involve AR-15s) and armor-piercing bullets. No, the “we” who don’t want to stop it, in this case is, beyond a small minority of zealots, the even smaller minority of those who are politicians, in Congress, in the Executive Branch, and in our statehouses.

Why would they do this? Or, rather, not do anything about gun violence? Well, there is a small minority of this small minority who are, themselves, zealots whose interpretation of the Second Amendment is such that our dead children are just collateral damage in pursuit of the higher cause of unrestricted gun ownership. But, for most, opposition to even the most rational restrictions is tied to money, specifically to money from the NRA. A staffer for Jimmy Kimmel, Bess Kalb, looked at how much each of the Senators and Congresspeople tweeting their sadness and condolences took from the NRA, noting that “In the 2015-2016 election cycle alone, GOP candidates took $17,385,437 from the NRA,” (quoting a tweet from Republican National Convention chairwoman Ronna Romney McDaniel), and that “This is NOT counting the $21 million given to President Trump.” Another article documents the individual contributions, led by $4.4 million to Thom Tillis (R-NC, or, excuse me, R-NRA).

These legislators, and sadly even the President, when not crying their hypocritical crocodile tears and then voting with the NRA to kill any sort of gun reform, talk instead about the need to focus on mental health. This, by the way, is a good idea; the mental health system in this country is terrible; insurance companies cover it inadequately, those who are not insured and need public facilities find them cut back yearly, and there is no shortage of news stories focusing on a poor mentally-ill person pushed out of a treatment facility found wandering the street, or worse. Our jails and prisons have become our new mental hospitals, documented, for example, in this comprehensive Atlantic article from 2015, “America’s largest mental hospital is a jail”. However, it is not the diagnosed mentally ill who commit these murders and mass murders. Most such murderers do not have a diagnosis, although they probably suffer from “anger management disorder” (not in the current Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), but “intermittent explosive disorder“ will be in DSM-V). This is important because it is the angry who commit these murders. An article in Slate by Laura L. Hayes from 2014,”How to Stop Violence; Mentally ill people aren’t killers. Angry people are”, contains this persuasive data:

80 to 90 percent of murderers had prior police records, in contrast to 15 percent of American adults overall. In a study of domestic murderers, 46 percent of the perpetrators had had a restraining order against them at some time. Family murders are preceded by prior domestic violence more than 90 percent of the time.

Hayes concludes that “Violent crimes are committed by people who lack the skills to modulate anger, express it constructively, and move beyond it.” Sadly, this also describes many of the most virulent opponents of gun control.

If anything could be even more sad than the fact that the mass killing of our children is tacitly endorsed through inaction by our political leaders, it is that it is only one face of the epidemic that is child mortality in the US. This January, Ashish P. Thrakar and colleagues published “Child Mortality In The US and 19 OECD Comparator Nations: A 50-Year Time-Trend Analysis” in the journal Health Affairs. The picture was bleak. The first sentence of their Abstract summarizes their findings: “The United States has poorer child health outcomes than other wealthy nations despite greater per capita spending on health care for children.” Guns are part of it, and the “social determinants of health”, a sanitized way of saying that in the richest country in the world there are millions of children with inadequate food, housing, warmth, safety, healthcare, and educational opportunities, are ultimately the other causes. We may be the richest country in the world, but we are also the most unequal in the developed world, and the increases in the wealth of the top 0.1% does not “trickle down” to those in need.

Indeed, even the outrageous and disproportionate child mortality rates in this country are not the whole story. As I have noted before (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015; Tom Petty, the opioid epidemic and changing structural inequities in the US, January 23, 2018) the US is the only wealthy country in which mortality rates are rising, a completely shocking finding since, of course, it didn’t used to be true. And this rising mortality is driven by the white non-Hispanic population (although, it must continue to be said, that the absolute mortality rate of minorities, and especially African-Americans, still exceeds that of whites), and more particularly, poor whites.

In a terrific effort to try to explain to the international community what is happening in the US, Steven Woolf recently wrote an editorial for the BMJ, Failing Health of the United States. He notes the causes of the increases in mortality (more than opioids, more than guns, although these are major contributors), provides data, and proposes solutions. “In theory,” he says,

…policy makers would promote education, boost support for children and families, increase wages and economic opportunity for the working class, invest in distressed communities, and strengthen healthcare and behavioral health systems.

Politicians need to address these issues, and they need to be made to do so. By us, the people they are supposed to work for, not the huge money contributors like the NRA. But we can only do this if we stay angry, and stay organized. We cannot heed calls to “not talk about this now” while families are grieving, because it will, based on history, not be very long before it happens again.

It is our job and we must take it on.