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15 “We Just Treat ’Em” In 1995, around the time that the Clinton Health Care Initiative went down in ›ames, bioethicist George Annas wrote an essay about ER and Chicago Hope in the Hastings Center Report, a bioethics journal. Annas presented an analysis of the series that was sensitive to the complexity of realism as a concept as well as to the functions of the program for society and the medical profession. He argued that “Chicago Hope is a stronger program substantively than ER” because of its penchant to deal more directly with the moral and legal dilemmas of high-tech care. He emphasized, though, that Chicago Hope’s strength on the ethical side did not mean that the program “mirrors reality.” The reason, he said, is that the series focused on illness and care as events, not processes. By the process of care, Annas meant a continuity of attention through relationships with various members of the health care team, including physicians. “Health care,” he pointed out, “is not the same as medical care, and under our quickly evolving health care nonsystem, more and more medicine will be practiced outside the crumbling temples of tertiary care. To the extent these shows mirror the reality of modern medicine , they mirror a reality mired in the already receding past of hospital -based, fee-for-service, doctor-patient medicine, rather than our for-pro‹t, capitated, population-based future.” Annas particularly aimed his ‹re on this issue at ER. The “real star” of that series, he said, is money, “and it is money’s remarkable absence that makes it the star.” He continued: 359 After all, as any health lawyer will tell you, the only place Americans (even those illegally in the U.S.) have a legal right to medical care, regardless of ability to pay, is in an emergency department. And in this TV-land ER everyone, regardless of race, class, age, or insurance status, gets immediate and compassionate care by dedicated professionals, no money questions asked. Given the show’s popularity, a reasonable argument can be made that such amonetary attention is what Americans want from their health care system. But ignoring the context of American medical care in terms of money, power, and control by managers and insurers, ER continues the socially unhelpful TV tradition of pretending medical resources are unlimited, money is no object in medical care, and dedicated physicians can and should care only about the patient they are currently working on. John Wells [ER’s producer], of course, knows this and actually sees ER as reassuring an anxious public about their medical care, noting, “This is a place where you go and you sort of know who the people are, and you feel that they care about you.” This is in direct contrast to what is going on in the real world. As more and more Americans are herded into capitated health care plans, these plans are making it harder and harder for their members to seek even emergency care without prior approval . The limited “right” to emergency care is being compromised in the name of cost-containment and ef‹ciency. Newsweek put the ER cast on its cover on 31 October 1994 with the caption, “A Health-Care Program that Really Works.” The reality is that new consumer protection legislation may be necessary to prohibit managed care plans from ‹nancially penalizing their members for not obtaining prior authorization for emergency care, an issue never even hinted at on ER.1 A systematic analysis I conducted with Rachel Gans of the doctor shows of the 2000–2001 television year validated Annas’s comments about the portrayal of health policy ‹ve years later. Sponsored by the Kaiser Family Foundation, we explored the extent to which and way in which health policy issues appeared in all seventy-four ‹rst-run episodes of the four prime-time ‹ctional dramas that aired during that period: ER, Gideon’s Crossing, City of Angels, and Strong Medicine. We de‹ned a health policy issue as a disagreement or expressed dissatisfaction with government or institutional rules about nonclinical issues in patient care. The shows averaged a bit more than one incident that dis360 | PLAYING DOCTOR cussed a health policy issue per episode; ER had the most at 1.36, while Gideon’s Crossing had the fewest with .65 per episode. Consistent with Annas’s impressions of half a decade earlier, resource concerns got short shrift. Fully 78 percent of the 127 health policy issues...


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