Equity in Medical Care: Are the Deserving Poor Eligible?

EQUITY IN MEDICAL CARE: ARE THE DESERVING POOR EUGIBLE? JANE M. ORIENT* Doolittle: What am I, Governors both? . . . I'm one ofthe undeserving poor: that's what I am. . . . But my needs is as great as the most deserving widow's that evergot money out ofsixdifferentcharities in one weekfor the death ofthe same husband. I don't need less than a deserving man: I need more. I don't eat less hearty than him; and I drink a lot more. . . . I'm playing straight with you. I ain't pretending to be deserving. I'm undeserving; and I mean to go on being undeserving. ... [1] Unless infinite resources become available, any system ofmedical care, including or especially universal national health insurance, will be required to base some decisions on economics. Who should pay die taxes and who should receive benefits first when the budget is tight promise to remain topics of Uvely controversy. That the rich should pay more, and the poor receive more, has become axiomatic. The implication in the tide that some of the poor might be undeserving is certain to offend Uberai humanists, who assume that all poverty results from unequal opportunities , strokes of misfortune, and other external circumstances. However, Uberai humanists are underrepresented in pubUc emergency rooms, where the staff does not respond to all patients widi equal sympatiiy. From the descriptions of patients diat follow, die reader may guess die reaction of the doctor on duty: A hobojust offdie freight train, dirty and sweating but sober, politely requests treatment that might ease the pain ofa second-degree burn acquired many miles back. A thirty-year-old veteran does not remember how he might have been exposed to Agent Orange, but he has been unable to hold a steady job, feels nervous all die time, and is going bald. He wants a complete checkup and compensation for the effects of toxic herbicides. ?Adjunct assistant professor, Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona. Address: 1601 North Tucson Boulevard, Suite 9, Tucson, Arizona 85716.© 1983 by The University of Chicago. All rights reserved. 0031-5982/83/2603-0347$01.00 Perspectives in Biology andMediane, 26, 3 · Spring 1983 | 411 A World War I veteran can no longer afford treatment for his deforming arthritis. Unfortunately, he was too busy working to apply for a serviceconnected disability, and his old records were destroyed in a fire. A patient with chronic lung disease, packs of cigarettes stuffed in his socks, demands immediate service. The last time he was hospitalized he melted his oxygen mask, unable to refrain from smoking even when near respiratory failure. A disorderly youth is brought in restraints after attempting to assault two police officers who caught him sniffing glue in a field. A disgruntled veteran who has been inadequately compensated for his diagnosis of antisocial personality held an administrator and a nurse practitioner hostage widi a .45. Several months later he requests admission to the open psychiatric ward because he is temporarily short of money to pay his rent. A patient has the sniffles and a mild sore throat. He needs an excuse for his employer so that he can get paid for taking several days off work. A young diabetic who refuses to take her insulin is in ketoacidosis for the third time in a month. She breaks her intravenous bottle on the bathroom sink and threatens the staff with the fragments. The Fire Department paramedics respond to an emergency call at 3 a.m. from a distraught modier whose infant has diaper rash. They advise her to change die baby's diaper several times a day but, since uiis is not New York City, refuse to transport her to the hospital. A dramatic scene occurs in the receiving area as a screaming young woman arrives by ambulance. Separated from her family, and placed in an examining room, she is unable to diink up a medical complaint. Late in the evening, a patient comes to request a refill on his (narcotic) pain medications, saying diat his niece emptied the bottle into the toilet. Fortunately his bronchodilators were rescued just in time. His record shows diat he always visits late at night, and similar...