Who's job is it anyway?

This week I have had 3 patients with alcoholism. The first is a man who bled from varices, small veins in his esophagus. The second is a woman who drank so much in such short amount of time (3 months) that she went into liver failure. The last is a young man (25 years old) who drinks 24 beers a night and had bloody bowel movements for 2 weeks and ignored them until his mom threatened to kick him out of the house unless he came in. These three patients have very different stories, backgrounds, problems- but the common theme is alcohol. Alcohol ruined their lives- and alcohol ruined their bodies. And in each case I was called to fix them.

So here's the question: Alcoholism is a disease unlike others because the beginning, middle and end of the disease lie with people's choice to partake in a substance that is dangerous, mind altering, and one that eats stomachs, livers, blood, the brain, the heart- and other organs for lunch. This isn't like cancer or a heart attack- people literally choose to pick up the bottle again and again. Often times patients come in to the hospital several times before alcohol starts to really do its damage. Indeed on a given Saturday night, the emergency room is swamped with drunks- sometimes college kids who aren't yet hooked, but often by homeless men and women- many of whom have educations and had jobs and families lost to temptation and addiction. Given this- is it my job to stop the bleeding? Is it your job to pay for me to do so if these patients (2 of the 3 in my case this week) don't have insurance?

A friend of mine who works for an insurance company tells me that soon premiums will be significantly higher for smokers. The moral: If you choose to ruin your own body, you can pay the lions share of your health bills instead of your smoke-free neighbors. As a doctor it's tempting to agree with this policy. Why not make people more responsible for their habits- if those habits cost (in dollars and time) society at large.

The problem with this thinking is the dangerously slippery slope it represents. Why stop at smoking? Why not make alcoholics pay? And what about those rumors circulating that obese people will soon pay more for airline tickets? Should they pay higher premiums, too? And now that we're penalizing, how about anyone who ever sat on a tanning bed. The minute they get a melanoma diagnosis, should they poney up $2000 extra a month for 10 years to cover the cost of malignant melanoma in a small percentage of the melanoma population? Should I pay for a high carb diet? Should someone who recovered from a cocaine addiction pay for a heart attack 30 years later that may or may not be related? Should a man who slept once with a prostitute in Vietnam and contracted Hepatitis B be penalized monetarily forever more? And on and on the scenarios go...

It is indeed my job to fix whatever problems come my way, at any hour, on any patient. I swore an oath to that affect when I graduated from medical school. But somewhere in the next 50 years we are going to need a oath for everyone to live by- one of less recklessness and one of taking care of ourselves. We can barely afford to care for our sick compatriots now- and with the economy on the fritz- business has never been better at the liquor stores. Still, we are completely backwards in our thinking if we try to penalize with money after the fact. Many alcoholics spend their money on alcohol and don't have a lot left for insurance. Those obese folks could use some education and some support- like free gym memberships, or 1/2 hour extra a day at lunch to take a swim in a pool located at their workplace- now there's an idea. Most studies have shown that money towards health education pays off. As soon as a multi-million dollar campaign in India to educate truckers who were spreading HIV/AIDS throughout the country by unprotected sex with prostitutes was launched, the rates plummeted. And when that campaign was no longer funded- you know the rest.

To my alcoholic patients I had this to say after I "fixed" them this week: stop drinking or you are going to pay. And I wasn't talking for a second about money.