Professionalism in Peril - Part 5: Our Obligation to the Poor
by Gene Rudd, MD
Today's Christian Doctor - Summer 2011
“In everything set them an example by doing what is good . . .” (Titus 2:7, NIV).
So far this series on Professionalism in Peril has looked at the historical meaning of professionalism as being an obligation or moral commitment; how our current overemphasis on autonomy undermines scientific and personal integrity; how God views the unjust billing practices so common in today’s healthcare; how “third parties” result in professional adultery; and how personal character is foundational to our professions. In this session we will consider our obligation (professionalism) to the poor.
What is the current state of affairs?
Do doctors of faith care more for the poor than our secular counterparts? Apparently not — at least under the broad definition of faith. In the May/June 2007 edition of the Annals of Family Medicine, Farr Curlin, MD, reported the results of a survey of 2,000 practicing US physicians in which he found that religious physicians are no more likely to care for the underserved. Disappointing, isn’t it? Even shameful. While not mentioned in the conclusion of the paper, data in the body of the paper and personal discussions with the author revealed that there was a group with “high spirituality” that did care more for the poor (39% versus the 26% average). When CMDA asked the same questions of its members we found their commitment to caring for the poor the same as Curlin’s “high spirituality” group. I was initially pleased until it occurred to me that still the majority of our members may not be serving the poor in any capacity.
In CMDA’s 2010 Membership Survey, 56% of the respondents reported taking care of the poor (the percent of their practice efforts were not defined). Since those who participated in the survey were somewhat more likely to be longer-term CMDA members than the average member, this datum may be skewed to those more committed. Nevertheless, many, but not nearly all, CMDA members have some outreach to the poor. But should we all?
What is our Professional Obligation?
The answer to this question depends on the era in which the question is asked. In generations past it was generally considered the duty of each physician or dentist to share in the care of the poor. It can be rightly argued that this obligation was in part stimulated by a social ethos — the concept of a “social contract” espoused by Rousseau and others. In Bird and Barlow’s review of medical oaths (Codes of Medical Ethics, Oaths & Prayers: An Anthology), there are references to the tradition of the physician’s obligation to provide care despite socioeconomic status or ability to pay.
It is helpful to remember that in prior days, the business of medicine was primarily “cash on the barrelhead.” As in providing care, the financial transaction of medicine was quite personal — face-to-face. In that environment, doctors more commonly linked their expectations and charges to what a patient could pay. In addition to this charity care, bartering was not uncommon.
Today, however, this obligation has been blunted by the sense that social systems should bear this responsibility. As one colleague stated, “I pay taxes to care for the poor. I’m also required to see non-paying patients in the Emergency Department. That should be enough.” While this perspective may seem harsh in the context of this article, with variation, it seems to be widely shared.
In our current healthcare system, over half of all physicians are employees, beholding to the policies of their employers. Unless the employer has a commitment to charity and allows that to be exercised at the doctor-patient relationship, most employed healthcare professionals do not have the authority to care for the underserved within their employment agreement and practice setting. And since so much of the business of medicine is managed by office staff inanimately relating to third party payers, there is less personal dynamics to stimulate charitable response.
In addition to loss of income, care for the poor requires other sacrifices. There will be a higher “no show” rate leading to scheduling problems. This is not difficult to understand when we consider how much less control they have over their lives. No childcare, no taxi fare, and perhaps no one else who even cares. There will be those whose crisis is self-inflicted by poor choices (sexually transmitted infections, gambling, alcoholism, etc.). There will be those who waste their limited resources of self-indulgences, neglecting their health, yet expecting someone to provide free care. Providing care for the poor requires overcoming these obstacles.
Logistical reasons explain in part why doctors are less apt to care for the poor, but there are other factors more difficult to face. Lack of compassion, greed, lack of courage to challenge the system, spiritual insensitivity, etc.; these issues of character need to be considered by each of us.
What would Jesus do?
Long before that question became popular as a bracelet inscription, as a teenager I recall the influence this question had on me when reading Seldon’s In His Steps. In that story, individual lives, a church, and a community were radically changed when people began considering and doing what Jesus would do.
To know what Jesus would do we begin by reading the Gospels. Jesus cared for the poor. Moreover, His teachings make it clear that He expects us to do the same. It is helpful to know that Jesus was not suggesting we could eliminate all poverty. For as He said, “The poor you will always have with you” (Matthew 26:11). Nonetheless, we have a personal responsibility to help those around us. In teaching us the importance of adding works to our faith, James says that religion that God finds acceptable involves caring for orphans and widows (James 1:27). I think this list was not intended to be exclusive, but rather an example of our obligation to help those in need.
In Matthew 25 Jesus shares the compelling story of a future judgment when we will be separated into sheep and goats. The goats will be cursed and cast out. Why?
“For I was hungry and you gave me nothing to eat, I was thirsty and you gave me nothing to drink, I was a stranger and you did not invite me in, I needed clothes and you did not clothe me, I was sick and in prison and you did not look after me. They also will answer, Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you? He will reply, I tell you the truth, whatever you did not do for one of the least of these, you did not do for me. Then they will go away to eternal punishment, but the righteous to eternal life” (Matthew 25:42-46, NIV).
Though it was shared in an earlier edition of Today’s Christian Doctor as an encouragement to care for the poor, an analysis of Jesus’ parable of the Good Samaritan bears repeating here (Luke 10). You likely remember the characters in the story; so I’ll ask you, “Which character(s) best represents doctors in our culture?” The robbers? Sadly we have bad apples among our ranks, but thankfully they are few. What about the man who was beaten and left for dead? CMDA regularly ministers to doctors who find themselves in the midst of a life crisis that overwhelms them. But again, at any point in time, that is a small percentage. Each of us would prefer to think of ourselves as being like the Good Samaritan — willing to sacrificially help someone in need. But for most doctors, help like this is the exceptional situation. As the statistics cited earlier show, a minority of doctors help the poor. Therefore, a good argument can be made for doctors being like the priest and the Levite in the story. They choose to walk down the other side of the road rather than engage the man in need. While we might think them simply hard-hearted, remember that they worked for an HMO. Well . . . not exactly. However, they were part of an institution that had rules that governed their behavior — too many misguided rules according to Jesus (Matthew 5:20). One of the rules was that they were not to touch the dead or dying. Such a distortion of righteousness led to their failure to meet the need of the man in crisis. I dare say that many doctors today feel likewise constrained by unrighteous rules.
But there is another character in the story that I think best represents doctors — the innkeeper. The inns at that time were the closest thing anyone had to a hospital. As demonstrated in this story, after emergency medical assistance was provided by the Good Samaritan, the innkeeper was the healthcare provider for inpatient care. Of particular note, the innkeeper was well paid for his participation. The Good Samaritan gave him two silver coins and the promise to add more if needed when he returned. By one theologian’s reckoning, two silver coins were enough to provide medical care for at least a month. We are left to wonder what would have happened if the Good Samaritan had only one silver coin to pay for healthcare. Would the innkeeper have participated? Or worse, what if the Good Samaritan could not afford to pay anything? Would the innkeeper have participated? What do you think most doctors today would do? Most importantly, what about you? Pause to differentiate between your good intentions and your actual behavior.
It is important to remember what led Jesus to tell this story. The “expert in the law” who was trying to trap Him asked, “What must I do to inherit eternal life?” When Jesus affirmed that the correct answer was to love God foremost and “love your neighbor as yourself,” the expert in the law wanted clarification on “who is my neighbor?” As Jesus’ parable reveals, our neighbors are those people who cross our paths who are in need. Their need, our proximity, and our ability to meet their need constitute an obligation. I’ll leave it to you to contemplate how responding to that obligation affects our eternal future.
So we’ve seen that, contrary to historical norms, most doctors today do not care for the poor. Even those doctors who are “highly religious,” those who are members of a Christian medical organization, perhaps only half care for the poor. More than abandoning our professional obligation to the poor, we who are followers of Christ have a moral obligation to the poor — an obligation somehow linked to the very core of who we are in Christ.
Should we be concerned? I think so. If you agree, what are you going to do about it?
ABOUT THE AUTHOR
Gene Rudd, MD, co-author of Practice by the Book, serves as Senior Vice President of the Christian Medical & Dental Associations. A specialist in Obstetrics/Gynecology, Dr. Rudd has experience in maternal-fetal, medical education and rural healthcare. He has garnered numerous awards including the Gorgas Medal. While working with World Medical Mission, he established the Christian Medical Mission of Russia, directed the rehabilitation of the Central Hospital in Kigali, Rwanda, and served in Belarus, Bosnia, and Kazakhstan.