Thoughts on Accountability

While working this weekend, two of our more frequent patients (aka – frequent fliers) came in, as they normally do, looking for help. One is a relatively young woman who is a three pack a day smoker with end stage lung disease. She is on a host of medications and uses oxygen nearly all the time now. In fact, she is also on a special machine (only one step removed from a ventilator) to help support her breathing at night so she does not die while she sleeps.

All of our efforts and abilities, while admirable, are for not as this patient refuses to do anything to help herself. She still smokes, is not compliant with her medications and has refused repeatedly to be admitted to the hospital because we won't allow her to smoke while an inpatient. She knows she is dying, yet she refuses to become a DNR (Do Not Resuscitate) meaning that when she finally does come in unable to breathe on her own, we will be compelled to place a tube into her trachea and place her on ventilator. This is a futile proposition because at her level of disease, she will most likely never be able to be removed from the ventilator.

The other patient we had is a frequent visitor who comes in looking for detox as he has been intoxicated most every day of his life for the past forty or fifty years. He is depressed and often just looking for someone to talk to because he has managed to drive away all his friends and family. He is frequently loud and obnoxious, often making a scene in the waiting room and causing other patients increased anxiety. He has been in and out of every detox and substance abuse program in this state (having signed out before completion, thus ensuring his return to drinking). His pattern now is to come in and state he wants to quit drinking; he manages to stay for a few hours and then will change his mind and tell us he does not want to go to detox. He is predictable and pathetic.

What both patients have in common is that they both utilize large amounts of resources for their medical care, yet neither one is willing to contribute to their own care. They essentially get free medical care through state and federal programs because of their level of income (both are disabled) and yet they both can manage to spend money on the things that make them worse, cigarettes and alcohol. Is this O.K.? Well, in the U.S., this is too often the norm. Patients are not held accountable for their own contributions to their poor health and the rest of us pay for their poor choices.

Why do I bring this up? Because I see huge parallels between these patients and the banking and financial system in this country. The taxpayer is again being asked to support another group who is not willing to take care of itself. Banks made bad loans; ratings agencies did not do their part to make sure that securities created with these loans were assessed appropriately; insurers then insured and re-insured the securities with such creations as the Credit Default Swap (CDS) and various other instruments, again not taking into account the original bad loans that had been securitized. Now that all of this has come to light, what have these folks changed in their behaviors? In truth, not much.

At some point (and I fear we may have already passed it) we have to become realistic and make people accountable for their own bad decisions. My patients described above have both consumed more than their share of health care resources. The banking industry, for its part, has just finished off a $750 billion dollar gift from the taxpayer and now they want more. They still have assets that must be written down because of their poor decisions. Well, I for one, am willing to let them take their medicine. I have seen enough human behavior to know that if we keep giving them money, their behaviors, like bad habits, will never change.