Moral Diversion in Medicine

Here’s my column in April’s Emergency Medicine News, on the problem of what I call, ‘moral diversion.’

Edwin

Our specialty has long struggled with the problem of diversion, in which overwhelmed emergency departments attempt to divert EMS patients to other facilities. It raises many questions, professional, financial and ethical. Therefore, most medical centers choose to accept all patients and live with overwhelmed, understaffed departments, with the intent of simply doing the right thing. (And avoiding the risk of litigation to boot!)

But recently, I began to contemplate the other form of diversion that is systematically crushing the emergency care system. A kind of diversion that impacts finances, staffing and ultimately the proper care of the sick, injured and dying entrusted to us. It is moral diversion. The displacement of moral respnsibility to another, out of convenience.

What I mean is this: one of the unintended but devastating consequences of our current health-care system is that it allows the progressive cascade of moral responsibility, for patients, providers, insurers and politicians, until all the problem in question lands itself squarely in an emergency department.

It’s ironic, really. EMTALA was meant as a fundamentally moral law. It was intended to provide excellent, timely emergency care for the poor and helpless of society. Now, by making emergency departments the final common pathway, by tying the hands of hospitals against any refusal of care, it has given much of our medical care system an endless ‘Option B.’

Option B is this: go to the ER. Have you called your physician’s office lately? The voice prompt will always say, ‘if this is an emergency, hang up and dial 911,’ or ‘if this is a medical emergency, go to the nearest emergency room.’

Fair enough. Some people need to be prompted to go to the hospital when sick, so they will not languish at home in dangerous conditions. And some facilities, and private offices, simply can’t be available to answer questions (or meet patients) all the time.

But those situations are not the main problem. Witness the progressive exodus of physicians from call schedules and indeed, from hospitals. Now, I understand why physicians leave. I”m not suggesting their motives aren’t sound. However, many primary care physicians are no longer available for consultation or for admissions of their sicker patients. Often, when their patients need to be admitted, they simply say, ‘go to the ER.’ The implication is, ‘the ER doc will figure it out and make things happen.’ The subtext is, ‘my moral obligation is discharged, because someone else will do it.’

Likewise with specialists. As highly-paid physician specialists take themselves off of call and open surgery centers or other non-hospital facilities, the emergency department is the default. Eye injury and no ophthalmologist? Not a problem. For the opthalmologist knows that the emergency physician will have to face the community’s ocular problems, and will find a way to send the problem to some remaining on-call ophthalmologist somewhere else. (Until that physician metaphorically ‘sees the light’ and leaves as well.)

The moral cascade says, in effect, ‘whatever I do in my community, it’s not so important that I have to be available. There is always another physician, and another person in my speciality, who will deal with the problem. I am not bound by a moral duty to the community; someone else will do the right thing.’

As much as I respect the financial imperatives of specialists, and as much as I applaud their pursuit of professional and economic freedom, their abdication results in part from the knowledge that the ER exists. And it is a tragic situation with tragic potential.

Where else does this moral diversion manifest itself? Certainly in the way government has mandated that emergency departments see everyone. Knowing that the emergency department is the back-up, government can risk crushing private medicine and driving physicians away from the bedside. Government can mandate insurance (which many will not obtain), knowing the hospital will have to eat the cost of the uninsured and small business the cost of the insured.

The government can run amok with medicine; refusing to pay while mandating care; imposing unscientific standards which cost more and do less; even failing to provide psychiatric care at the state level while insisting on psychiatric detentions for the safety of patients and society.

In general, government also worsens care by demanding burdensome regulations and elevating cost, regardless of the effects ‘on the ground.’ Government can endlessly impose rules ‘for the health and well-being of the people,’ conveniently casting the moral (and financial) obligation away from itself and onto practitioners. And blaming the medical system when its own system fails.

Finally, the moral diversion of emergency care can happen at any level. The law enforcement officer can drop off the violent psychotic patient ‘to get the help he needs,’ the social worker at 5PM on Friday can leave the homeless, ‘where else can he go?’ And the family member can bring anyone, anytime, saying, ‘I’m not taking her home; something has to be done. By the way, I have to leave…’

In addition, patients can ‘run out’ of all medications and wait until dangerous symptoms arise to come to the emergency department. Patients can neglect chronic medical conditions, and routine visits, and even post-surgical follow-up, knowing that the emergency department will sort it out. People can, and do, routinely abuse their bodies with drugs, alcohol and violence, knowing that help is an ambulance ride away, and that it need cost nothing.

All of this might have created an incredible opportunity for our specialty, if not for the immoral financial shifting of the greater moral diversion. We are uniquely situated and trained to ‘stand in the gap’ of every crisis. But sadly, our very essential nature has left us underfunded to do the work to which we are called, and to fulfill the myriad duties thrust upon us by this tragic diversion, this tragic dereliction, of responsibility on many levels.

I know we’re all proud of what we do. The work of modern emergency medicine is thrilling and rewarding. There is great honor in doing the hard work that others find too difficult. And I understand the struggles of other specialties. Quite frankly, everyone is under the gun, from politicians to patients.

Still, we all have a duty to behave in a moral manner. We all have an obligation both to ourselves and our community. And we all should expect ethical behavior of those who want us to behave ethically.

America’s emergency departments can do a lot. But they can’t do it all. No matter how convenient it is to say those five magic words that dispel all accountability: ‘just go to the ER.’