Often I’ve heard that “these people” should have the personal responsibility to take care of their issues. If they have primary care physicians, why don’t they try to go to them? It turns out they’re free to do whatever they choose, even if that’s make bad choices. What they’re not free from are the consequences. Every action, the saying goes, has a reaction. Every choice has an effect. Many of my colleagues have noted the choices made by patients have costs. “Your tax dollars hard at work,” I hear. As if the prescription was to simply cut them off. As if the prescription was to erect a barrier or a filter so only the “right” people get seen.

My point is this: in this country, we’re free to do as we please. Often these choices have consequences that reverberate beyond just ourselves. In fact, they often impact the community negatively. This is where our freedoms are supposed to end, but it’s never that clean. There are only so many resources out there and not enough hospital beds for the population. EDs, for example, get very crowded (albeit for many different reasons), impacting everyone who works there and everyone who comes to that ED in need. So are we then to limit everyone’s freedom to self-determine? Are we to tell people when they can and cannot decide it’s an emergency? Or are we free to self-determine?

Some of you might rightly point out that we can’t afford to let everyone utilize resources endlessly. That we all have a responsibility to the broader community to be a steward of resources and to not run our country into bankruptcy. That there are limits to freedom. You’re probably right, but maybe we in medicine should be talking about those limits. The great majority of the cost in our health care system is spent on the sickest patients. The greatest source of our long-term debt in the country is the cost of health care. Maybe we in medicine have a responsibility to our country. However, I’m pretty sure that when sick patients show up in your ED, you do what I do and try to save them.

This is what we’ve trained and studied for. We get up for sick patients. I’ve heard nurses complain, “I’m bored. We need a good code.” It sounds awful, but it’s what we do. We like to treat sick people, not the “riffraff.” Yet, those sickest people who we save, those septic 72-year-olds or diabetic 56-year-olds having strokes, those are the ones who cost the most. Hands down, no doubt about it, the sickest people cost the most. If you’re worried about the cost of health care, then you’re worried about this problem. Our country seems to be generating disease, like obesity, cancer, and diabetes, at greater rates. Are we going to treat all of them when they show up? Or can we turn that trend somehow?