One of the unique things about emergency medicine in America is a law called the Emergency Medical Treatment and Active Labor Act, or EMTALA.  Under this law, any facility that accepts Medicare cannot turn a patient away for financial reasons.  I have said, in many columns, that the idea was reasonable…when first passed under Ronald Reagan.  Very unstable patients were sometimes sent, without arrangements or stabilization, to county/city/charitable hospitals when they should have been initially treated at the for profit facilities where they arrived.

Of course, like every ‘good idea’ from government, bad things arise.  One of these is that people do the math and bring even the simplest of problems for free care.  And another of these, in a struggling economy, is that emergency departments bear the brunt of uncompensated care.  Which means, physician and hospital incomes fall because patients no longer have insurance, or physicians, and come to the emergency room.  When physicians, like myself, suggest that we’d like a tax credit or something for seeing many patients for free, we’re told by government ‘you chose that specialty.  You can choose to do something else.’  Not strictly true, since almost all ER’s fall under EMTALA.  But I guess the bottom line was,  we made a choice.  OK.  I’ll live with it…for now.

Moving on.  I had a conversation with some local educators yesterday.  Two of my sons, who are bright, articulate home-schoolers, would like to take welding at the county public school career center.  They aren’t allowed, despite my paying property taxes like everyone else.  One person, an educator I respect enormously and consider a dear friend, said simply, ‘you chose to home-school.’

Interesting.  My choices, which were made in good faith, to do good things, to serve the public and care for my own family, are somehow things which lock me into a certain trajectory.  A certain tax bracket.  A certain derision, even, as a high earner who should simply carry on doing the right thing as benefits, salaries and respect slip away.

On the other hand:

If I suggest that I should not have to treat an addict because of his or her ‘choices,’ I would be considered the cruelest of cruel.  If I had the option, and elected not to give care to the young man with gonorrhea because ‘it was his choice to fool around,’ or the cocaine induced heart attack, who ‘chose’ to use drugs, I would likely lose my license.

Those who choose to overeat until they can’t walk are rewarded with disability.  Those who choose to have multiple children out of wedlock are given state support.  Those who choose not to go to school, not to work hard at an education or trade, are met with sympathy and programs to get them ‘back on track.’

Choices are essential in a free society.  I just think it’s fascinating how we ‘choose’ to reward or punish them. Especially for those who try to choose the right thing.

Edwin

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