by Harry Goldhagen
First published December 11, 2002 in Medscape Infectious Diseases
In The Way of the World , William Congreve’s witty Restoration comedy, Mirabell, the gambling, worldly man-about-town, is in love with the beautiful, charming but willful Mrs. Millamant. In Act I he makes a startling revelation:
“. . . I like her with all her faults; nay, like her for her faults. Her follies are so natural, or so artful, that they become her; and those affectations which in another woman would be odious, serve but to make her more agreeable. . . . They are now grown as familiar to me as my own frailties; and in all probability in a little time longer I shall like ’em as well.”
I can remember reading this years ago and thinking poor Mirabell was deluded by love. He wasn’t talking about Christian charity or other forms of forgiveness. Rather, he found to his surprise that to know someone this well was to love them even more. What madness!
Sure, it’s easy to feel compassion and sympathy for the blameless patient — a child with any sort of disease, the victim of a motor vehicle collision, someone who acquired HIV or hepatitis from a blood transfusion. But how do you feel about those who, because of their lifestyle, brought their disease on themselves? Do you like these people for their faults? We have discovered so much about the causes of diseases and how to prevent or postpone them, anyone can now learn how to live a long and healthy life. In fact, here’s a brief list summarizing what we know about maintaining good health:
- Avoid using tobacco
- Eat a low-calorie, low-sodium diet high in a variety of fruits, vegetables, and whole grains
- Drink alcohol moderately
- Exercise regularly (strength training, aerobics, stretching)
- Get all recommended vaccines, and be screened regularly for age-appropriate diseases
- Participate in a monogamous relationship, or be celibate or practice safer sex
- Drive safely
That covers the causes of most of what we suffer from. And it is only natural to conclude that anyone who doesn’t follow this healthful life doesn’t deserve our care. Certainly not someone who smokes — it’s his fault he developed emphysema or lung cancer. Or that morbidly obese woman with diabetes and hypertension whose health is rapidly deteriorating on so many fronts. If only she’d lost weight and eaten a healthy diet when you told her to, she wouldn’t have these problems. And not that alcoholic with cirrhotic liver failure who requires a transplant. Or the man with HIV, whose disease is the price of his lifestyle, the result of his disregarding basic principles of safer sex. Why should we waste our valuable and limited medical resources on such people?
Many people believe that no one is less deserving of medical care than those in prison. One reader was bothered by the fact that the state he lived in provided organ transplantation for convicted murderers. He asked, “How far should you go to perpetuate the life of a convict who is serving a ‘life sentence’? Should you administer antibiotics and vaccinations? Should you provide organ transplants? What about cornea transplants? Should you treat injuries — cuts, broken bones — or should you ‘let nature take its course’?” As he saw the ethical dilemma, “A key factor would seem to be in providing care that deprives other — perhaps more deserving individuals — of treatment.”
On the face of it, who can argue? Organs are in short supply, and why should someone who has stepped so far outside the bounds of society take what should rightfully go to law-abiding citizens? Let’s disregard the fact that people in prison are the only group that is guaranteed adequate healthcare by the Supreme Court (under the “cruel and unusual punishment” statute). Why should we bother treating murderers, rapists, child molesters, drug dealers, and thieves?
Just as with more or less deserving patients, where do you draw the line? It’s a slippery slope once you start thinking about it. Sure, talking about those murderers with life sentences pushes our buttons. But most people in prison aren’t murderers — the majority are locked up for drug-related crimes, thanks to maximum sentencing regulations in most states. In my opinion, to talk about the few murderers instead of the masses of people who are warehoused in prisons for crimes we can deal with in other ways really diverts our attention from the real issue — that most people in prison are poor and uneducated, that they suffer from the diseases that are overrepresented in that population group, such as HIV, hepatitis, and tuberculosis, and that they require treatment, both for their own good and for the good of the community once they are released.
One of the people who has taken on the challenge of providing treatment for people in prison is Anne De Groot, MD, of Brown University, Providence, Rhode Island. De Groot and her colleagues, Joseph Bick, MD, from the California Department of Corrections, and many others, are involved in the HIV & Hepatitis Education Prison Project, which promotes awareness of our responsibility to treat this significant portion of the population, estimated at nearly 3% in the United States (a higher per capita incarceration rate than almost any other developed country). And because “Incarceration concentrates individuals who have had poor access to healthcare and extensive exposure to communicable diseases,” as they state in the October 2002 issue of HEPP News, treating such patients provides an excellent opportunity to prevent the spread of HIV and other sexually transmitted diseases, tuberculosis, and hepatitis B and C to the populations with the highest incidences of these diseases.
So when you find yourself providing different levels of care on the basis of where a person fits on your unexamined sliding scale of how deserving a person is, take a moment to consider where you fit on that scale. Are you perfect? Do you live a blameless, healthful life that is free of risks? And if you are one of the rare ones who does, don’t you think you might want to assist the rest of us?
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