S1E16: The Ethics of Health Care

Harjit: Open this, and I will make sure it doesn't close.

Leen: Please fasten your seat belts. Hello, Moto.

Bushra: All right. Let's do this.

Leen: Let's do this.

Margaux: All right.

Leen: I love those commercials.

Margaux: Hello, Moto.

Hey, everyone. Welcome to the "Bundle of Hers." Margaux here, and we have everyone in the studio again, so Harjit, Leen, and Bushra. And today, we wanted to talk about something that came up in one of our classes.

So as part of the curriculum here at Utah, we have a class called Layers of Medicine, which is our humanities course. We talk about the things that make a doctor a doctor that aren't found in textbooks. Many of the topics we've talked about on this podcast have reflected what we talk about in Layers of Medicine.

And so a recent issue that came up . . . We read an article about whether undocumented immigrants should receive basic healthcare here in the U.S. And that sparked the question surrounding this podcast, which is, "Is healthcare a right or a privilege?" And we, as the "Bundle of Hers," unanimously agree that healthcare is a right.

For me personally, having recently taken the Hippocratic Oath and learning about medical ethics in class, I believe it's completely unethical to deny access to healthcare to people.

I want to open it up. Harjit, what do you think, or what are your opinions on the ethics or universal healthcare as a right?

Harjit: I think that ethics are ingrained in all decisions that we make. And I also, like you've already mentioned, believe that healthcare is a right. I think that's something that I came in believing when I started medical school or even understanding what medicine means to me.

I think we're guided a lot by the way that we perceive information. For me, that's something that I have formulated, and I think it shows in all the work that I do.

I know there are a lot of things that a person has to critically think about before giving the knowledge that they have or utilizing it for a solution. But in that same sense, being healthy or getting to a point where a person is healthy, I think, that's an ultimate goal we all have, and I want to support that. And so, for me, I believe healthcare should be given to anyone and everyone.

Bushra, you had a thought?

Bushra: Yeah. So, for me, the way that I look at it is if something is not all right, then you basically have to . . . it's either a consumer good where you basically buy whatever is needed, and that's the way healthcare is for the most part in this country. It's a consumer good. You buy it if you have the means, or you get it through your employment.

But some people do have full-time jobs, they work 40 hours plus, and still can't afford healthcare. And so, for me, when I think about those people who don't necessarily have a job that's willing to give them health insurance or they can't afford it through their job, the fact that they work very hard and still can't get adequate healthcare, to me, is a travesty.

And so, when I think about it as a good and people who need it . . . Everybody needs healthcare. Everybody needs to be healthy, right? And if you can't get it because you can't afford it, that's where the ethical issue . . .

Harjit: Dilemma comes in?

Bushra: Right.

Harjit: So I have a question. Are you saying it's more of an accessibility thing?

Bushra: I think it is something that we need to provide everyone in this country, because we all need it at one point or another. I'm a healthy 24-year-old right now, and I don't have any health issues at this particular moment, but there will be a moment in time where I will need to have access to healthcare.

And some people might argue you always have access to healthcare because you have your emergency rooms and blah, blah, blah, but that's not where we should be getting regular checkups. Our main doctors shouldn't be the ER physician. You know what I mean?

Harjit: I agree.

Bushra: We need primary care. We need our own primary care physicians. And I think that would probably alleviate some of the issues that we do have with ER wait times and stuff like that.

Margaux: So we all agree that it should be a right and it is unethical to not have equal access to healthcare. But the unfortunate story is that in our country, there is a huge gap in the access to healthcare, as Bushra was just mentioning. And from our perspective, this seems to be very divided among the borders of socioeconomic status.

And so, Leen, earlier when we were talking about this podcast, planning it, you had an interesting example. Do you want to share?

Leen: I know earlier we mentioned how healthcare . . . we all agree that it's a right. I know that there's a view out there that rights are given to people who are of a certain nationality, have a certain documentation, or people who have not had those rights revoked, as in being in prison.

I'm posing this as a question to all of us. What are your guys' thoughts on healthcare for those who, for instance, are in prison versus someone who is not, and the access to healthcare? There is a different quality of care that is given to each side and access issues for both. So what are your guys' thoughts on that?

Margaux: I think that presents an interesting paradox, Leen. One person in the community who can't afford health insurance, that same person in prison has probably access to excellent healthcare. They could get chemotherapy if they needed it.

And I agree, prisoners have just as much right to healthcare as any other citizen of the world. But in our country, that person, unfortunately, has to be in prison to get that healthcare if they can't afford it outside of prison.

So I think that's a very interesting dilemma and paradox that we have in our community. I don't see how we can offer it to prisoners but not extend that out to the general population.

Bushra: So, basically, everything that goes into the prison system is taken out of taxpayers, right? The food, healthcare, all those things that are necessary to keep a person alive that they get is through taxpayer money. And so I just don't understand why we don't extend that to everyday working citizens in the United States.

I think a lot of people are just afraid of, "Well, I don't want to pay for someone else's healthcare." But we have a lot of things that are socialized in this country. The police department, the fire department, all these examples are of things that are socialized, meaning . . .

Harjit: Public education.

Bushra: Public education. People have access to these things. And so that would be my solution, is to have something like single payer healthcare to remedy that.

Harjit: I've noticed that humans are very motivated by money and . . .

Bushra: Of course. Yeah.

Harjit: And so I think the issue then becomes that the people that are in charge of making these decisions . . . We often think about ourselves first. So I wonder if that's playing into . . . And that's where ethics gets confusing, because you can do a million different things, but you can only do so much if you don't have the support of the systems with you.

You know what's really difficult being in this field? We're going to become physicians, right? And these kinds of things are going to impact our care. Sometimes I almost wonder, if I had no outside influences and I could just do my science, just do my medicine, how the outcome of my patients would be. We have to think about all this.

It makes our job harder, which is okay because we should be thinking about every single piece of the puzzle. These are things that when I was going to come into this field, I was thinking about that. I want to do a million things, I want to save a million lives, but I can only do so much. I would say not only this field, but I feel like a lot of things are money-driven.

Leen: So this reminds me of something that I heard. I can't remember where I heard it. I was listening to the radio or reading an article. I can't remember exactly. But capitalism is a huge part of this issue, especially when it comes to insurance and affordability.

There was a note in what I was reading or listening to about how the insurance companies are now stepping into the role of the physician on telling you the time of care that you can provide, the amount of care you can provide. They don't have the right or they don't have the license to practice, yet they're stepping in our positions, or as physicians, they're stepping in their positions and saying, "This is what you can offer and this is not."

And so the article was based around, "It's time for physicians to step back up and show the insurance companies that, "I have my license for a reason, and this is my right to practice." What is it called when you're allowed to work with patients and provide healthcare advice?

Margaux: License to practice.

Leen: License to practice, whereas insurance companies do not have that. They come from a money point of view.

And so the article was saying, "When are doctors going to step up to the plate and take their place back as the physician when it comes to insurance companies so that we can fix this gap?"

Margaux: Do you remember, did the article say or suggest any ways that doctors could step up?

Leen: So the article was saying when insurance companies are making these criteria for how long a person can be treated for, etc. . . .

Bushra: Or what they'll cover essentially.

Leen: And what they'll cover. Exactly. The physician needs to be on board and say, "No, this illness, whatever we're treating, takes this long, and this is what we're going to be expecting to follow up." And they need to very much voice their medical knowledge, or part of it, in these decisions.

Bushra: For me, when I think about what you're saying, Leen, I think that insurance companies have a lot of power, right? This is essentially how you're going to get paid.

People, normal people, the average American can't afford the astronomical healthcare costs. I think I read somewhere the number one cause of bankruptcy in this country is healthcare related. And so they can do that because they're the ones that are basically going to pay you as a physician, and anything extra has to come out of the patients' pockets. If you can't afford it, if you don't have the money to pay for it, you're not going to pay it. And so it's just . . .

Leen: Right. So there has to be some type of . . . that's a big issue that needs to be addressed. I don't know what the solution is, but there has to be a change to that system.

Bushra: I think relinquishing some of the power that insurance companies have would be a great start. But I think getting everyone on the same page to that is also different. Basically, you have to change policies, right? If you want to change that, you have to make policy changes, which is a step ahead. And to make policy changes, you have to get involved with the government. And so that's where it gets . . .

Leen: Which is a whole other frustration.

Bushra: That's where it gets tricky.

Harjit: But this brings up actually a really great point. I think a lot of times we as professionals think we're only going to do our job, right? But we forget that, again, everything's tied to a system. And for that, I think as medical students, we need to take that initiative to learn about government, learn about policymaking, learn about how we can be a part of changing healthcare, because we're the ones who are meeting these patients.

And that's something I've even noticed is maybe a little bit missing in our education. What do you think is a solution for that, for us? I know it's something that we shouldn't be expected of because that's not the reason why we started, but it impacts the way we're going to give healthcare.

So my first question is, do you think that all physicians or to-be physicians should understand the government system, should understand healthcare policymaking? And second, should they be a part of it? What do you all think?

Bushra: I think that's an individual basis, right? For me, I would say I would want to be a part of it because I would see the impact of it, and I would know better than some lawmaker who sees it from the outside and who might be influenced in other ways to make decisions against what I would deem acceptable.

So I would say, yeah, I would want to be involved, but it's an added thing that you have to do on top of your job. You know what I mean?

Harjit: Yeah. That's my whole dilemma, too. I want to see that healthcare is getting to my patients in a certain way, but that also means that I have to be a part of making change. But that also means that I have to do a whole bunch of extra things that I thought I would never be doing. But now that I'm growing up here and understanding how the healthcare system works, it's something I feel like I almost have an obligation to do.

Bushra: Yeah. And also, I think we usually think from a primary care perspective. But if I'm specializing in something and I'm making a lot of money and a lot of these things are benefiting me, I don't think that I would want to change anything per se.

Harjit: I get that.

Bushra: I don't know.

Harjit: I think that's where the internal conflicts come in. So, Margaux, kind of that same question. I was wondering, do you think we should be, again, involved in healthcare policymaking as physicians?

Margaux: I think we should. And like you said earlier, it is unfair that that's something that maybe we have to add on to our already arduous workload that we'll undoubtedly have as physicians.

I think it's one thing about the way our government is set up, is that we do have a voice. But like you said, I don't know what those channels are, or how to get there, or how to advocate for policies that I want to see changed, or even what the first step in doing that would be. And like you emphasized earlier, I think that is something that is lacking in our medical school education.

I would love to take an interprofessional class with law students, and I think it would be great for them to learn how the medical profession works in isolation and we learn how you go about making policy changes or fighting current laws. That's just something that I think would be very intriguing.

I don't know if any medical schools across the country are doing that right now. If you're a listener and that's part of your curriculum, we'd love to hear about it.

Harjit: You brought up a really great point. I think to change anything, you need to add your voices and experiences. And I think a lot of the times we have that fear of, "Can we speak up about this?" But it's literally just how you feel.

And I feel like that with the podcast that we're doing. Knowing how we can think about different perspectives, I think that helps us a lot.

Leen, do you also want to add on to this?

Leen: I'm thinking about this, and I think it's very ironic from my perspective. When applying to med school, or ever since I wanted to be a doctor, people would always ask me, "Why don't you be an international representative in politics? Because you really want do global health and things like that." And my response was always, "I don't want to be the person on top making rules below. I want to be the person down on the field making the change because I think the system takes forever to work."

And I think it's ironic now going into the medical field. Who else is going to be the representative at that level? Who else is going to be the representative in the system? If we have the insurance companies do it, that's where we're at right now.

So it's kind of like a love-hate relationship in my aspect. It's like, "Ugh, I hate dealing with policies in terms of making them." I like a system set, and I like to work within my limits within a system and apply what I can do to help directly. And now I have to go and learn law? That sounds boring. That sounds so bad for me. I don't like it.

Bushra: Daunting, too.

Margaux: What do you guys feel like as medical students, right now, in the system that we are in right now, we can do to help combat this unethical dilemma we're posed with?

Bushra: So I don't think there is much that we can do as a medical student, even as a resident, and maybe even as an attending. I doubt that there is much that we can do at the moment.

But I think at the level of . . . we have midterm elections coming up in 2018. That's where the real change happens, is when you elect officials who have your best interests at heart. And so the best way to do that is to go out there and vote for policies that you believe in and people who will implement those policies.

Leen: I think what we can do is . . . as daunting as it sounds, education is a big part of it. We need to understand now how the system works and then how it works around the healthcare field so that once we get into it, we'll be more knowledged in that. We'll find more outlets if we need to and . . .

Margaux: Harjit, what about you?

Harjit: I think that it's important that when we meet with patients, we understand their perspective of how money is impacting the decisions they're making. With that, hopefully, we can see how they're feeling about this.

I know the experiences my parents have had with insurance companies, right? But I wonder if this is something that a lot of people feel. If I see any trends, that's something that I could watch out for.

Another thing I think is important is just really knowing how to do our own jobs well, getting the practice, learning how to figure things out well so that when we do practice, we choose cheaper options. We choose options that can get the job done.

And then like I had already said, I think just making sure our voices are out there. I know that we are medical students, but even if it's just a discussion with our classmates, to start thinking about these things.

A lot of people don't know how to answer things because they've never been questioned. And I think I've noticed that I've changed a lot when people have started asking me questions. Then I start thinking of things that I never would've thought of. Now that we are having this conversation, maybe because of this in the future, I will make a different decision.

Margaux: Harjit, I think that's such a great point, the maintaining the attitude that we can make a change even if we don't know how. Just having the idea in you to be empowered to figure out how is so important.

Harjit: Yeah. So while recording this podcast, we put up a Story on our Instagram page, that's @bundleofhers for those that don't know, and we asked the question, "Is healthcare a right?" So the results that came out in the last half hour were 86% say healthcare is a right and 14% think that it's not a right.

It's really informative that there still is that side that some people don't think it's a right. So I think that's also another thing that we can work on. We can understand the people . . . I think in this room, we all agree that it's a right, but really understanding why people think that it's not a right.

Margaux: So we'd love to continue the conversation, whether on our Instagram or Facebook page. Leave us a note as to why or why not you think healthcare is a right. And also, if you haven't done so already, please subscribe to our podcast wherever you download your podcast, and we'll tune in with you next time. Thanks.

Harjit: I liked that.

Leen: We made it.

Harjit: I think it worked out.

Bushra: Want is like, "I want a Lamborghini."

Leen: I know.

Bushra: But do I need one? No.