It’s the political season again, and we’re talking about liberty, freedom, and responsibility in public. It doesn’t matter if you’re Democrat, Republican, Independent, or apathetic; you’ve probably heard the noise from the debate. You’ve probably also heard it in your emergency department.

Usually it goes like this: “Why is this patient here?” Within that little question lies the entire debate about liberty and responsibility. These are patients who have exercised their freedom to seek care at a local ED for what appears to be a less-than-valid reason. For their troubles, they often get some “constructive” feedback:

• “Kid’s got a fever? Did you try Tylenol? No? OK, let’s try Tylenol.”
• “No, I don’t write notes for work.”
• “No, I don’t refill morphine ER scripts.”
• “You’re 18. Does your back really hurt you that bad? Let’s try Tylenol.”
• “No, the mole doesn’t look any bigger in the time you’ve been here.”
• “Yes, we do have a drug that starts with D. Lots of them. But let’s try Tylenol.”

During a string of night shifts recently I saw many of these patients. In my group, in conferences, in articles, and in online commentary, I have heard many people suggest these patients do not need to be in the ED. I don’t disagree, but back to my original question, are we free? We have a system of government that allows people to self-determine. You can do almost anything you want without someone looking over your shoulder. Even illegal activities are possible if you want them badly enough. Want to do meth? How about drink alcohol all day? Eat junk food because it’s the least expensive? Watch TV and sit on the couch endlessly? You’re free to do all of that.

In fact, those of us in emergency medicine have a job because of these freedoms. I call them the “4 Bads”: bad genes, bad habits, bad choices, and bad luck. (You could add bad policy, but I digress.) Most of our “don’t need to be here” patients fall into one of these categories. Maybe it was the meth addict who was brought in by police after being up for three days. Or maybe it was the alcoholic guy who has been in your ED more times than you have. Or maybe it was someone who needed a note for work. Whatever it was, I’m certain there was a patient on your last shift who met these criteria. People who could have and should have known better. People who could have and should have sought treatment beforehand.

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?

Are we free to self-determine? Are we free to choose an unhealthy life if, at the end of it, we help to bankrupt our country? Is it other people’s business what you do on a daily basis, knowing that health is a set of habits you keep? In this country, people are free to choose as they wish, but it’s often the broader community that cleans up after them. We in emergency medicine are part of that community, often the business end of it. We may grouse about patients who abuse the ED, but all of us have the responsibility to make better choices. That could be how you treat your next patient or how you choose to manage the stress that comes from treating those patients.

I look at the ED as a public space, which can be used by anyone. In that public space are all the issues that our country has to offer. We can choose to make things better or worse each day, with each patient. We may not save a life each day, but we can touch one. In many of our EDs, we see the effects of poverty. Like many school districts around us, we will soon be asked to account for quality outcomes but not given credit for the effect that poverty has on those outcomes. Let us not assume that “these people” have some moral failing that they need to dwell upon. Let us not assume that “these people” deserve our scorn or our criticism. They need our help, not our judgment. I believe that we understand very little about the needs of the very patients who show up in our department. We may assume they want drugs or free stuff, but have you ever asked? Has anyone ever studied it or taken a survey? What we have in our EDs is nothing less than a real-time, ongoing needs assessment for the community around the ED. “These people” who show up to the ED inappropriately are the very ones who, without intervention, will end up as the sickest patients we all trained for. I think it’s in our long-term interest to take advantage of their presence and get a lot better at meeting their needs. In short, we need to better serve “these people” and seek to understand their problems.

We in EM need to prevail on our leaders and on society in general to improve our country’s health. If we cannot successfully address the bad choices and bad habits that lead to many of our patient’s illnesses, there will be more sick patients than we can shake a stick at. While this is what I trained for, I don’t believe this is good for our country. Whatever the solution, we will have to act more like a community and less like free individuals who have no connection to one another.

Dr. Vasquez is an emergency physician who has been practicing for 10 years and currently serves as a medical director at a hospital in Arizona. In 2010, he served as President of the Arizona College of Emergency Physicians.