A 78-year-old African-American, Mrs. M suffers from multiple health problems, including congestive heart failure. Living in a public housing project and relying on Social Security income, she receives some help with household tasks and transportation from her unemployed son. At home, Mrs. M can move about slowly, and even then only with the help of a mechanical walker. Even with the walker and her son's assistance, it is almost impossible for her to leave the house and get around the neighborhood.
A wheelchair would help, though buying one is out of the question with so few resources. One day, Mrs. M's son contacted his mother's Medicaid representative, requesting assistance. The representative refused, saying that Mrs. M's condition didn't warrant such an expenditure, and besides a physician would have to state that she needed it to get around. While they were visiting a local public health clinic, the son approached the medical resident on duty and asked her to mark "yes" on the insurance form, indicating that his mother needs a wheelchair because of her inability to walk.
The physician refused, regarding such "fudging" to be fraudulent because Mrs. M could indeed walk around her apartment. The son became agitated, accusing the physician, who was white, of refusing to help because of prejudice. Upset, the resident suggested that the son call Medicaid to appeal the restriction on wheelchair coverage, arguing on the basis of patient welfare and the probability that preventing injury in this case would be more cost effective than denying the wheelchair.
Enter the Parable
The Medicaid rep denied the appeal, saying that if the woman is careful she can do perfectly well with the walker. The doctor then offered to refer the family to other options that might help. The son wasn't mollified: "No one will help us. My mother wants to get out and see people; she needs the chair. You're her doctor, and you could help her now. Why don't you be a Good Samaritan?" Stung by this question, the physician wondered if she should just fill out the form and authorize the wheelchair.
The problems the resident encountered—from dealing with a belligerent patient to confronting a system that ignores or rejects those it claims to serve—illustrate not only that poor patients but also well-intentioned doctors and nurses often meet frustration and resistance dealing with access to healthcare resources. Bound by a web of policies, regulations, and perhaps prejudices, the system does not successfully address concrete problems surrounding health care for marginalized people; it also seems to inculcate certain attitudes about providing the minimum of services-anything more that supports one's quality of life is unavailable.
Could the son's reference to the Good Samaritan offer guidance in this case? The son's statement about the Samaritan clearly struck a nerve: the resident chose medicine as a way to help people in need, "binding their wounds" and caring for them, as the parable suggests. What would the Good Samaritan do for Mrs. M? How helpful is the parable as a guide?
To begin with, the parable is simpler than the real-life situation. The Biblical story is not complicated by the practical problems of access to healthcare resources faced by the poor and marginalized in a complex, post-industrial society. The Samaritan has no problem meeting the injured man's needs—he has money to offer. Had the Samaritan lacked the means to pay, would the innkeeper in the story have been so obliging? In addition, the resident in this case is not herself a marginalized character, as is the Samaritan in the context of his day. Instead she is a central figure in health care, one who possesses a good deal of power and authority, whose actions can redirect the flow of dollars to provide what her patient needs. But how can the physician be a good neighbor?
The resident is not certain Mrs. M needs the wheelchair to ambulate and doesn't want to fraudulently say otherwise. She tried to help her patient by urging patience and appealing Medicaid's denial. Government programs and social service agencies designed to serve the poor, however, are overwhelmed by demand and are sometimes staffed by uninterested personnel who seem innately suspicious of requests for additional help. After all, there are alternatives: if the son got a job, his employer's health plan might pay for the wheelchair, or he might be able to pay for it out of pocket. Appreciation of what the wheelchair represents-greater mobility and interaction with her community-are lost on the physician.
Beyond Money and Means
Clearly the resident feels obligated to advocate for her patient. She could tell herself that benefiting Mrs. M outweighs her duty not to deceive the insurer. This moral calculation suggests that the physician find a way to game the system to obtain the care Mrs. M wants. One ethical rationale might be that the injustice of the system is greater than the injustice involved in misrepresenting the facts. Besides, the costs of future ER visits or hospitalizations will far outstrip the cost of a wheelchair; in some sense, then, falsifying the form could result in saving the system money in the long run.
Mrs. M's case, however, illustrates that money and means aren't always the whole problem. It also speaks to the role of power relationships. The son is urgent and impatient because he is struggling to gain a benefit that his mother needs. And she needs it now. Maintaining patience through a long appeals process is a quality of relative privilege, available to people who can afford to wait. Recommending patience to someone like Mrs. M is tantamount to recommending deference to those with power. Mrs. M's need is now; the physician can help her now. What's wrong with that? Wouldn't it be nice if good Samaritans abounded, freely dispensing resources?
Bending the Rules
And, to be sure, a wealthy patient who needed the rules bent a little could do so. Yet the system resists those at the margins, even when they have an ally or advocate.
But back to the parable. The point of the story is not that the Samaritan has the means, money, and power to dispense care and needed resources. This kind of Samaritan would be hard to bear in at least two ways. First, although merely marking the form to secure the wheelchair is tempting, such an act reinforces Mrs. M's dependence on the more powerful physician, reminding her of her dependence and undermining her sense of autonomy and self-reliance. Such an outcome could reinforce feelings of resentment that maintain an adversarial relationship between those who need help and those in a position to grant it. Second, if patients experience their physicians as deceptive to third parties, even if the result benefits the patient, the effect will be to erode patients' trust in the truthfulness of their physicians.
Finally, the parable simply isn't a precise fit for this case because the story does not offer an anthropological model of human interaction or an ideological comment on justice and socioeconomic conditions, but a theological perspective. It says that we all live close to the edge, on the road from Jerusalem to Jericho, with our sense of power and control largely illusory, our lives contingent, one stroke away from a wheelchair ourselves.
In addition to duties to the individuals in our care, we also have duties to protect the common good. Responsible stewardship of shared resources means that we should ensure that resources are distributed equitably and fairly. The current healthcare system is fragmented and unjust because vast numbers of persons lack adequate access. Gaming or fudging on behalf of one patient does not make the system more just and violates the duty of responsible stewardship.
The lesson of Jesus' parable, therefore, is not that the Good Samaritan is the neighbor we should expect when we are in need, but that we are all neighbors in need. Fudging on behalf of one patient does not make the current health care system more just, but illustrates the ethical principle of "everyone for him or herself." Since we all someday will find ourselves lying by the roadside of good health, we should work to find ways to distribute health care resources in a way that enhances the qualities of our lives.
