The President has recently created a fuss regarding the provision of free access to contraception by groups that morally oppose its use. The White House and most of the media have made this out to be issues of reproductive rights and the right to basic health care. Others, this writer included, frame this argument as a violation of the First Amendment. Ironically, but not unexpectedly, the ACLU, the group founded to protect the Bill of Rights, is silent on this constitutional infringement.

I’m not opposed to contraception. Have at it, but don’t violate the constitution in order to give something away for free that can be easily purchased after a visit to the clinic. Separation of church and state was conceived to keep the government out of the affairs of the church, not the converse. Our early settlers and generations to follow fled countries where church and state were tightly intertwined and those who sought religious liberty were persecuted.

This is clearly a case of the government meddling in church affairs, something the founders strongly opposed. The President came to realize this and conceived a “compromise.” Instead of forcing a church to behave in a certain manner, he has chosen to force private insurance companies to give away contraception to the employees of certain organizations.

This fails the constitutional sniff test as badly as the individual mandate does. By what power can the President or Congress compel a business to provide a service for free or a citizen to purchase a service against their will? (Public utilities would be an exception.) There is no constitutional basis for this. By this logic, fulfillment of basic needs such as food and shelter could be mandated by the government. Restaurants would be required to give away free food to the hungry, and hotels would be required to allow the homeless to occupy their empty rooms.

For now, no citizen is required by the government to give away goods or services. Each state and county must arrange for the implementation of the safety net to ensure that the social and legal needs of the poorest citizens are met. Individual citizens help those less fortunate on a voluntary basis. Pro bono work is suggested for attorneys but not required. Implementation of these regulations to force action by citizens would be uncharted waters. Or would it?

No citizen is compelled to provide free service – nobody, that is, except emergency physicians and on-call physicians. We are the only indentured servants of the federal government. We are the only citizens who not only are compelled to provide free service but also do it under threat of a large fine for failure to comply. Indentured servants eventually are freed of their obligation. After 7 years they are granted freedom to find work where they please. So, what does one call a worker who is forced to provide a service without compensation for an indefinite period? A slave.

No citizen is compelled to provide free service – nobody, that is, except emergency physicians. We are the only indentured servants of the federal government.

I am not suggesting that this type of slavery bears any resemblance to the pre–Civil War conditions where slaves were deprived of every liberty that we cherish. I am referring to the economic slavery we have endured since 1986, the year EMTALA was passed. Over the past 25 years, we have provided billions of dollars of free care. This is a good thing. These patients require care, and we are eager to give it. What is lacking from the federal government is an acknowledgment that this mandate is unfunded and some dispensation is deserved.

One may argue that we send bills to these patients. This is true. I will concede that as a valid point when someone shows me a successful business model for a motel or restaurant that takes all comers (even those in their slippers and undershirt), does not charge up front, and sends bills in the mail. I’m standing by.

I’m not even asking for back pay. I figure that in 23 years I probably have given away over $2 million of free care. I don’t expect to see that any more than I ever expect to receive a check from Social Security. What I do expect is that our government should stop the slavery and formulate a plan to in some way recognize our unique status in the health care universe.

One might suggest that the government just pay us or allow us to write off the bad debt. Possibly if every politician resigned on the same day and only property owners elected new representatives this might happen. This is less likely than the winning Ohio Lottery ticket being delivered to me by flying pigs, so it is best not to dwell on such ideas.

Since we won’t get any financial break, at least the government could provide a break on the litigation side. This won’t cost a thing. Our malpractice premiums would decrease quickly along with litigation stress. As an added benefit, eventually physician behavior would change and the amount of unnecessary testing would fall. Emergency department and on-call coverage would improve as well. This would be good for patients and doctors. The only losers are the trial attorneys, which makes this très bien. H.R. 5, which recently passed in the House [see story on p. 1], would accomplish these goals. Write to your congressional representatives to encourage their support.

Emergency physicians tired long ago of extending a helping hand only to have it bitten by a patient who never intended to pay the bill and some shark from the back cover of the phone book.

The reach of the federal government has been too wide for too long. This will be a campaign issue this year, so it is a perfect time for us to point out that if the government shouldn’t force insurance companies to give something away for free, it shouldn’t be forcing us to provide a service for free either.

It is time for emergency physicians to stand up, stick their head out the window, and yell “STOP THE ECONOMIC SLAVERY!”

Be strong.

Dr. Baehren lives in Ottawa Hills, Ohio. He practices emergency medicine and is an assistant professor at the University of Toledo (Ohio) Medical Center. Your feedback is welcome at David.Baehren@utoledo.edu.