By: James Felman, MD

I have often wondered what the Nazi doctors felt like when they donned their white coats and stood on the platform directing new arrivals at the concentration camps to life or death. How did their value system become so deranged as to allow or encourage physicians to become comfortable with their role in deciding which human beings had any “value” and which were of “no value” and appropriate for death? Was this corruption insidious? Do doctors, as Grodin and Annas have suggested “anywhere, regardless of their specialty, have the potential to become perpetrators, and in Nazi Germany and other countries, many do?”(1)

The Emergency Department is the portal into the increasing dysfunction of both the national and global health care delivery systems. The economic “value” that so powerfully defines which human beings are worthy of care has become an accepted reality. And physicians have become all too willing participants in this triage system. I recall in the days before EMTALA seeing uninsured acutely ill patients who were placed in cabs and sent to Boston City Hospital by residents from Harvard hospitals. I wondered what the impact was on these physicians in training for their complicity in this economic triage.

Recently I cared for a young woman who had arrived from another country with a new diagnosis of breast cancer. She and her husband appeared terrified with her diagnosis and the uncertainty of her treatment. Even in a hospital with a mission to serve the underserved, her pathway to treatment was far from clear. I could remember all too well my own irrational terror well beyond medical knowledge when my wife received a diagnosis of breast cancer. “Poorly differentiated adenocarcinoma” the pathology report indicated. Visions of malignant cells doubling in a Petri dish created a palpable fear that every day of delay in treatment would adversely affect her outcome.  Without health insurance or a medical visa, there was no assurance that this patient from the patient’s country could or would be treated. The pathway from Logan airport to our hospital was and could no longer be a pathway to care for anyone at any time and at any cost.

During my over three decades in emergency medicine I have cared for many patients who have arrived at our ED in desperate need of medical care. One family carried an older man from  another foreign country to the airport in his country and from arrival at Logan airport to Boston City Hospital. He had a large symptomatic subdural that required urgent neurosurgery. One week I cared for a young woman who arrived from South America with substernal chest pain as her chief complaint. She mentioned something about kidney problems to the triage nurse. She had end stage renal failure with uremic pericarditis requiring emergent hemodialysis. Another patient, a European professional who was attending a conference in Boston had an acute febrile illness prior to her departure from Europe. She arrived in severe respiratory distress from an atypical pneumonia and required several days in the ICU. Finally, an older woman from Europe who was “just visiting” family members presented with chest pain and many untreated co-morbidities.  The technology of airline travel has made the Logan to Boston to ED a pathway for those with unmet health care needs to seek access to care.

Lest someone think that there will be a simple “left, right” solution for those who seek medical care by considering patients such as these “alien” (e.g. not human) – a phrase that should have a powerful resonance with all heath care providers as harbingers for what comes next, the ED also is the pathway for those who are unable to access care in their own states.  I have also treated a truck driver from out of state who indicated that he could not obtain health insurance who presented with uncontrolled diabetes, hypertension and chest pain, a refugee from a different state who had severe lung disease from his life as a factory worker and a patient with decompensated psychosis who got off an interstate bus and came seeking emergency care that she could not obtain in her home state.

I return to my thoughts about the Nazi doctors. I believe that a system that places an explicit economic value on human life and uses this determination in the calculation for who lives and who dies is dangerous both to patients as well as providers. Fundamentally, physicians should not participate in such an economic triage system. I am not so naïve as to suggest that it is possible to provide medical care to anyone regardless of the cost. It is also clear that it would be impractical to perform “medical screening exams” for everyone who arrives in our state or city by any method of transportation (border crossings? airport screenings?) in order to prevent those who are sick or injured from seeking medical care. The magnet effect of “free medical care” is a real phenomenon and was not infrequently mentioned as a reason why someone sought care at the old Boston City Hospital. There are many unmet health care and other needs of our own residents.  And yes, health care has real costs and there is no such thing as “free” medical care.

However, there are some steps that could be taken to address these economic costs other than denial of care. States could be required to cover the emergency medical costs of their residents who lack health care coverage and seek emergency medical care in another state. Similarly, there could be a global approach to addressing the economic costs of emergency medical care to reasonably deal with immigrants, undocumented workers or travelers who require emergency medical treatment.

Fundamentally, physicians should remain committed to their ethical obligation to deliver health care justly. I have indicated that I will not stand on the platform to participate in the selection process.  The effects of becoming comfortable with determining “worthiness” should give us all pause. Been there, and seen that done.  And with the deconstruction of the ACA, don’t think that sick people will not be denied access to health care.

  1. Grodin M, Annas G. Physicians and torture: lessons from the Nazi doctors. Int Rev Red Cross 2007; 89: 635-654.

 

Faculty Author: James Feldman, MD