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.