Sunday, September 08, 2013

Can I Be Your Doctor If....?

Last week, ClinkShrink wrote an article about a heinous criminal who committed suicide while in prison.  She titled her post: Your Patient Died. Who Cares?

Such a post begs the question of whether all people deserve equal medical care, equal physician devotion, and equal medical resources.  I think we all have our own beliefs about such things.  Some of us can minister to the physical and mental disorders of those who've done awful things, some of us can not.  I guess you could go further and say what's an awful thing?  Can you treat Hitler?  His bodyguard died a few days ago, having made it to the ripe old age of 96.  Can you treat someone who only killed 5 people, and not 13 million?  Can you treat someone who drove drunk and killed a single young child?  Can you treat someone who beats their children?  Who cheats on their wife?  Who causes their own illnesses by drinking, drugging, and eating pizza (~I ate pizza and ice cream at the beach today, it was sooo good, but I do know this is not good for me).  Who has religious beliefs that your own religion deems unacceptable?  And if your father ends up in jail because he drove while intoxicated, committed some sort of financial fraud, or there was a weird case of identity confusion that took a little while to sort out, would you want him getting reasonable medical care during his stay in jail?

Does everyone deserve the exact same medical care?  Is is wrong if one person can afford to pay out of pocket for more attentive care or better doctors or more expensive medications if those things aren't allowed by the Blue Insurance that most people get?  What if the person who says he can't afford such concierge type care puts in granite counter tops, wears designer clothes, and drives a luxury sports car, while the person who opts for high-end concierge care drives a used Chevy and shops at Wal-mart?   I've found that even in our world of haves and have nots, that often those with private health insurance are the have nots because certain treatments are deemed 'not covered' and there is no rhyme or reason as to who can get what.

Questions of how we divvy up our medical resources are difficult.   

But I'm going to move us back to the question of treating Clink's prisoners.  A doctor doesn't have to work in a jail, but if a doctor does  choose to work in a jail, or in an ER that happens to service the drug dealers who shoot at each other,  then that doctor is obligated to provide the best possible care to those patients.  Sure, people quietly judge, but if a doctor can't turn that off and offer the best they have to offer any patient, then they have no business being a doctor in that setting.  Should prisoners get the same care as model citizens?  No one's asking me, so I won't bother with an opinion, but I do think that those carrying for the prisoners need to be their agents, they need to advocate for reasonable standards of medical care for their patients.  Just like those taking care of the medical needs of those who are obese, mentally ill, or smoke, doctors need to offer the best care they have available, without stigmatizing the patient.

So Clink, I don't care that your patient died, but I'm glad you do. 


Sharon Aumani said...

Great questions, Dinah; ones I'm sure many of us struggle with, consciously [preferably], or not.

Even though I think it's important to be aware of a person's history, it's also important to tuck it aside somewhere; meet with the person before you. Do whatever you need to do to cultivate compassion for yourself and others.

Anonymous said...

You know, I don't think there's any person in this world, whether we consider them evil or saint, rich or poor, a detriment to their own health or not, who is undeserving of the same access to healthcare as the rest of us. They may receive some of that healthcare in a different format than others due to being in jail where they can't simply walk themselves to the hospital, but the quality of care shouldn't change because of a label society has placed upon you or because you made mistakes in your life.

I don't believe in a God, but if there were a God I don't believe he would look kindly upon any person who felt it acceptable to decide who should die, and by grouping people and then removing their access to healthcare that is precisely what a person, or group of people, are doing.

I do care that Ariel Castro died, because there's a hole in the system somewhere that allowed it to happen. Would we be upset if it were somebody who committed suicide while in jail for marijuana possession? Would we be upset if we later found out that a person who committed suicide while incarcerated were actually innocent of their crime? These scenarios may not apply to Ariel Castro, but the hole he hung himself from could be used by somebody who we wouldn't believe worthy of death next time, and that is reason enough to care about Castro's death the same we would any other.

So, while I may not be a psychiatrist working in an Ohio jail (I am neither a psychiatrist nor do I live in Ohio), I care as well.

Joel Hassman, MD said...

Would those of you who care that Ariel Castro died the way he did still have the same position if he had harmed someone in your family?

And, are you really thinking about how do envision a family member being kidnapped and repetitiously raped for years before you reflexively start typing a reply? And this perpetrator having contact with you or other family members while the victim was still in his custody?

Envision those little details.

Anonymous said...

What I disagree with is that the working poor are often turned away from receiving cancer treatment because they are uninsured or under insured (unless they qualify for medicaid), yet we give prisoners the latest and greatest cancer treatment. Is that fair? Why are the lives of the working poor less valuable than a prisoner's? In the U.S. the folks who get the most screwed are the working poor.

Gwen said...

I agree with the poster who says that prisoners have better access to care than the working poor. It's sad and should be rectified. Remember that movie Sicko where Michael Moore shows up at Guantanamo (I think that was it) with 9/11 rescue workers who were still suffering from their 9/11 related illnesses and asked that they get the same quality of care that the evil doers were getting inside Guantanamo.

Anyhow, I was watching an episode of Merlin on DVD and in it Merlin has to decide whether or not he will save the life of Uther Pendragon. Merlin is not an Uther fan (he's killed off plenty of wizards, witches, and magical creatures). He would far rather Arthur become king sooner rather than later. It would be safer for all magical beings. So, he turns to the fair Gwen. Uther executed her father. So Merlin asks her what she would do if she had the power of life and death over Uther. Would she kill Uther. She said no. Merlin asked her why. She said that is because it would make her no better than Uther. She would be a murderer. Merlin chooses to prevent Uther's death.

A very good point the Lady Guinevere makes. I guess we could lock all the criminals up, let them rape, murder and suicide as they will. But would that make us any better than them? Would we just be hurting ourselves and becoming worse people?

What if you saw someone, who you really wouldn't mind seeing dead, about to attempt suicide AND you had the ability to prevent it. Would you? Say Ariel Castro is about to hang himself, you are right there, and all you have to do is call for a guard and stop it. Would you?

I think that I might take Gwen's position. I might feel like a murderer after that.

Dinah said...

Joel, I think it's fine to refuse to treat someone who has violated you or your family members -- it would be a conflict of interest to treat someone who killed someone you love.

Prisoners should get a reasonable level of health care. The working poor should as well. Our current system is a travesty.

Anon: as much as I think the working poor get the short end, I'm not aware that poor people here get turned away from cancer treatments.

In mental health care, however, the more expensive treatments are simply not available to the working poor, and sometimes not to the well-insured. There's no rhyme or reason to why one person can take emsam or abilify or cymbalta or zyprexa and another can not. And I've heard of health insurers requiring doctors to spend half an hour getting preauthorization on medications that cost $5/month. What a waste of our healthcare resources.

Zoe Brain said...

If you have a lot of spare time... please read the judgment in the Kosilek case. (PDF).

In summary, the Massachusetts penal authorities have left every stone unturned, showing deliberate bad faith, perjuring themselves, just to deny this prisoner treatment.

They're still doing it, with deliberate obfuscation and delay wherever possible.

From a legal viewpoint:

Furman v. Georgia, 408 U.S. 238, 269 (1972)
"The right to be free of cruel and unusual punishments, like the other guarantees of the Bill of Rights, may not be submitted to vote; it depends on the outcome of no elections. The very purpose of a Bill of Rights was to withdraw certain subjects from the vicissitudes of political controversy, to place them beyond the reach of majorities and officials and to establish them as legal principles to be applied by the courts."

Brown v. Plata 131 S.Ct. 1910 (2011):
“To incarcerate, society takes from prisoners the means to provide for their own needs. Prisoners are dependent on the State for food, clothing, and necessary medical care. A prison’s failure to provide sustenance for inmates “may actually produce physical ‘torture or a lingering death.’ ” ….Just as a prisoner may starve if not fed, he or she may suffer or die if not provided adequate medical care. A prison that deprives prisoners of basic sustenance, including adequate medical care, is incompatible with the concept of human dignity and has no place in civilized society.”

Kosilek v. Spencer [889 F.Supp.2d 190 (2012)]
“Denying adequate medical care because of a fear of controversy or criticism from politicians, the press, and the public serves no legitimate penological purpose...It is precisely the type of conduct the Eight Amendment prohibits.”

Joel Hassman, MD said...

I have never, ever, advocated for denying care, I am just saying very simply it is not realistic to go a full court press for every single person, especially in correctional facilities. If he hid he was suicidal, that does not mean you force additional staff to attend to this one person, and focus on one person because you THINK he/she might harm oneself inside the cell for a PROLONGED incarceration stay.

I don't understand this concern for the welfare of people who have no concern for the welfare of others based on the crimes convicted.

As the protagnonist said to Batman during his training in the movie "Batman Begins", "criminals thrive on the indulgence of society's understanding."

You can agree or disagree. But, to sympathize with one who has no sympathy, well, ask Syrians how that is going!

Anonymous said...

Dinah, unfortunately the working poor do get turned away from cancer treatments. I've seen it multiple times. Many times they can not even get through the front door (e.g. they have to show evidence that they have x amount of dollars in coverage or the ability to get ahold of it - i.e. sell property, etc.). If it's an emergency, then of course they will be stabilized but that doesn't mean they are going to get the course of treatment they would have had if they were a prisoner, had medicaid, or had good insurance. They will be sent home. I've seen it happen.

Call one of the major cancer treatment centers and tell them you have a crappy policy with a low life time maximum of $20,000. I bet you won't even get an appointment. I would bank on it. The prisoner would get an appointment, however.

The working poor are the ones getting screwed. They would be better off if they robbed a bank.

Anonymous said...

I'm not advocating that we deny treatment to prisoners; however, we should not be proving them with care we do not provide the working poor. And, we do. That is valuing the lives of prisoners above the working poor, and that's not right.

Zoe Brain said...

The problem isn't treating prisoners with the minimum degree of decency consistent with basic humanity:
It's that you don't treat the working poor to the same standard.

Most other countries understand this.

Instead, the US gets situations like this one :

"If it is called manipulation, then out of necessity because I need medical care then I guess I am manipulating the courts to get medical care," he said.

Zoe Brain said...

This is not a "single isolated incident" using the same standard modus operandi.

Deputy Mark Nikolai, sheriff's office spokesman, said a man entered the Bank of America branch, 9171 S.E. 82nd Ave., at 10:20 a.m. and approached a teller.

"He handed over a note saying 'This is a hold up. Give me a dollar,'" Nikolai said. After receiving $1, he "had a seat in the lobby."

Alsip, who told police he had no permanent address, does not have a criminal record in Oregon.

Nikolai said deputies determined that Alsip sought to be arrested so he could get medical care.

Joel Hassman, MD said...

Well, we need to define what is "medical care", and what is minimal insurance coverage to allow a person to see a doctor and be offered minimal efficacious services, at best.

Case in point, see "PAC insurance coverage in Maryland", here is one link (that you will have to copy to link to at the address spot above):

Quite the read. Doesn't cover prenatal care, what a great beginning to learn. Oh, and it covers prescriptions, so they say. Yeah, ones from the 1990s at best. You can hope your primary care or psychiatrist will go to bat and write a strong advocacy for authorizing a brand name drug, but, when they turn down hydroxyzine HCl for a cheap anxiolytic or sleep aid, don't get your hopes up.

And seen a correctional medication formulary lately? Again, you will wonder what decade you are in. So the commenter above gives an example someone got arrested to get access to medical care. Doubt it was anything of real impact.

Tell my patient I saw today, who has PAC, why she can't get the MRI that NIH documented she needs to finish the work up to rule out crucial differential diagnostic likelihoods like MS or a lesion causing occult seizures; but no, she is instead referred to me, a psychiatrist practicing at a rural community mental health clinic because the neurologist who was kind enough to do a cursory eval advises instead to see me and make sure she doesn't have pseudoseizures.

Because her insurance won't pay for the standard of care workup a tertiary care program responsibly advocated for. This is what you folks are going to be dealing with when PPACA (Obamination Care in simplier terms)goes into play and will basically give the uninsured today. Including those prisoners, at best. Kinda ironic the letters PAC are in the abbreviation for the legislation, EH???

But, to return to the gist of this post, why do we care when horrendous people are imprisoned for decades and decide to take their lives? Note it is NOT about someone else killing him. That is the point I take from Clink's prior post and this follow up post now.

Didn't this site have quite the post and thread per arguing for the right to suicide? But, the rules change when someone is in prison?

Consistency, sensitivity, and attention to detail, I hope we are not missing those important elements to the discussion.

Ah, the sensitivity part is remembering those three women who lost 10 years of their lives to this "man". If interested, I have their picture at the bottom of my last post at my blog re this very matter.

And, I finish with this little tidbit to keep the discussion in appropriate perspective: paying attention to those initially arrested and put in JAIL is a different story than those convicted and long term incarcerated in PRISON. How many unfortunate suicides of people who were overwhelmed by their incarceration occurred in JAIL versus PRISON? Yes the former deserve monitoring, the latter, well, on a CASE BY CASE basis to me.

Just my opinion, as always.

Sunny CA said...

I think that what you are asking can really be boiled down to asking if people who do "evil" things are actually "evil" to the core.

As someone who taught (for one semester) in a really bad school, some of the worst students in the school. I had classes with more than one student wearing tracking "ankle bracelets", so the court system could keel track of these kids who were already convicted criminals.

MOST of these kids, even the convicted criminals, and criminals among them who had not yet been caught, were kids I developed a deep attachment to. MOST of these kids were not "evil to the bone".

Out of about 150 students, there were 2 I was unable to see the "good" in, but even with those two, it does not mean that there was not "good" in them.

I believe that "yes" criminals should get food, clothing, protection from abuse, medical care, warmth and cooling as needed, and an opportunity for rehabilitation.

If we give all those things to all the criminals, what does it matter that a small percentage were worthless human beings. The rest of the prison population do have positive qualities, and many can be rehabilitated.

Many will be released and live among us, so we will be better off as a society, to treat all prisoners humanely.

I care about them. I see the prison population as similar to the population of mentally ill. They have lost their rights, but deserve humane treatment.