A Greater Truth
Should someone have to lie to get care? For millions of uninsured Americans, finding a way to receive health care is a challenge. In my practice, I've been seeing more and more of the following:
"Where have you been living lately?" I ask my third patient of the morning, a heavy-set, forty-nine-year-old man with dark, weathered skin and rough hands.
"I've been staying with my friend," comes the casual reply
"How long have you been staying there?" I continue.
"You know, for a while." His tone is a bit guarded.
"How long is 'a while'?" I am wary now.
"You know, a bit of time." I can see that I'm making him uncomfortable.
"A month, six months?" I persist. "A year, two years?"
He capitulates. "Maybe a year or two."
I sigh inwardly. Instead of starting my conversation with "What seems to be the matter today," I am vetting his housing status. For eight years now, my clinical practice has been exclusively with the homeless of Cincinnati, and despite our program's generous definition of "homeless," this man does not qualify for our services. He is in need, yes, but he still does not qualify.
I know too well what to say.
"Mr. Johnson, we are here to take care of homeless people--people who live in the shelter or on the streets or are temporarily doubling up with someone. I'm sorry, but we just don't have the resources to care for people who have housing."
"But it's not my apartment, it's my friend's." Now it's Mr. Johnson who's being persistent.
"You've been there over a year--that counts as steady housing," I explain. "I can give you a list of the community health centers in town. You can call them--"
He cuts me off with a dismissive wave of his hand. "I don't got no insurance, and they want twenty dollars before they'll see me. I don't got any twenty dollars."
I've been here before; I know all the arguments. It can take six to twelve weeks to get an initial appointment at the community health centers. There will be paperwork to qualify for reduced fees, and he will still owe co-pays and charges. The centers' budgets are as tight as ours. They need to find every dollar they can, too.
imagine how difficult it is for an ex-con, a high school drop-out...
I sigh again. I know I'm going to fall off the balance and tip toward the patient: "I'll take care of you this once, Mr. Johnson, but you really need to call one of the health centers and make an appointment. They won't charge you twenty dollars if you can't afford it, but you have to complete the financial forms."
Mr. Johnson visibly relaxes. He can be the patient now, not a suspect. We move into the typical doctor-patient rhythm of questions and answers, stories and listening, the laying on of hands and stethoscope.
Like so many of my patients whose very survival has been a decades' long struggle, he looks closer to sixty-five than forty-nine. His clothes are threadbare, wrinkled and mismatched, and he layers up several shirts and light jackets to stay warm on this cold spring morning. He describes a cough for several weeks, shortness of breath going up the stairs to the apartment ("my friend's apartment," he reminds me) for months. On his lung exam I find scattered wheezes with decreased breath sounds.
Over the years, I've become experienced at asking the personal questions: "Your cigarettes--do you buy them at the store or roll your own?" "The couple of beers you drink most days, are they forty-ouncers?" But Mr. Johnson is reluctant to answer any query that doesn't sound "medical," such as his smoking, drug and alcohol history. He's clearly alert to the potentially disastrous repercussions of another "wrong" answer.
We reach the end of the visit, and Mr. Johnson leaves with an albuterol inhaler, some medical advice and a list of community health centers. Although he seems slightly more satisfied than when we first met, neither of us can fully overcome the awkwardness of my having more or less accused him of not really being homeless--of being a liar.
Our program offers what a lot of poor people need: high-quality primary care with no co-pay or fees. But our services are only for the poorest of the poor. If you are lucky enough to have some money and wisely decide to spend it on housing, then you lose access to our services.
Unless, of course, you lie.
Which more and more people do. When I first began working here, only a scattered person now and then would stretch living with a roommate into "doubling up" or would claim to "stay at the shelter" when she actually lived in the apartment building down the street. Now it's several people every week (at least, those are the ones we catch). They're the ones for whom lying doesn't come easily--they'll stretch the truth into homelessness or hope that their difficult situation will sway us. The hardened, experienced liars, I'm sure, slide right by us.
The philosopher Immanuel Kant says that lying is always morally wrong. Utilitarian ethics, however, posits that to judge the morality of a lie we must first balance the benefits and harms of its consequences. A utilitarian ethicist might say that if lying is necessary to maximize benefit or minimize harm, it may be immoral not to lie. The challenge, the moral pain, lies in correctly gauging that benefit or harm.
While I am bound by the rules regulating our program, I'm also a utilitarian when it comes to ethics--and maybe even an enabler when it comes to lying. Over the years, I have seen the difficult, complex lives my patients lead. If it's hard for a college graduate from the suburbs to find a job, imagine how difficult it is for an ex-con, a high school drop-out or a former drug user.
How, I ask myself, can I be a physician to this person without also being a healer, a helper? My patients probably know that my admonishment "I'll see you just this one time" really means "As long as you can lie enough to be convincing, I will keep giving you medical care."
Two months later, Mr. Johnson is back. Whether he's armed with the truth, or with the lie I taught him, I don't know.
"Mr. Johnson," I begin, "I thought you were going to call the health center and see one of the primary care doctors there."
"Well, I had to leave my friend's apartment, so I'm out on the streets for a few days, and that inhaler you gave me last time helped a lot, so...."
About the author:
Nancy Elder is an associate professor and research director of family and community medicine at the University of Cincinnati; since 2003, she's also been a family physician at the Cincinnati Healthcare for the Homeless Program. "While most of my publications have been research studies, I have used the arts--written and visual--to teach students and residents for years, and have been an itinerant creative writer when moved by personal and life circumstances. It is personal relationships and interactions that shape my career as both a family physician and a qualitative researcher."