No Payment — Adult or Child

A 24-year-old unemployed man presents to the emergency department with a complaint of a sore knee which has not been injured recently but occasionally gives way (most likely, a chronic injury of the cartilage of the knee joint). He wants an evaluation and something for the pain. Prior to treatment, he is questioned concerning his ability to pay and method of payment, and he responds that he will pay his bill personally.

Comment: Unknown at the time to the emergency department (ED) clerks is that this man owes more than $2,000 for eight prior ED visits over the past two years. The patient obviously knows that he will not pay his bill.

The man thinks that he needs treatment for his knee, and he recognizes that no one else will see him without payment. Yet his seeking treatment in the ED seems to constitute theft of service and certainly creates indirect charges (to make up for lost revenues, equipment, medications, etc.) to all of those patients who do pay their bills. Is this fair to them?

If the physician evaluates the man and discovers that no emergency exists, should he be treated anyway? If the physician refuses to treat the man, is he just passing the ultimate cost of treatment on to others? Would the physician's decision be different if the patient were a six-month-old child with a fever and an ear infection who was brought in by a mother who had the same history of nonpayment of bills? Would the physician's decision be different if he worked for a privately owned minor emergency center whose policy it was to require payment prior to treatment?


This case raises the issue of the responsibility of the individual patient to pay for his care. Since there is no emergency, the patient with the sore knee has no claim against any particular provider to receive the care he wants without payment. It is his responsibility to provide for his own medical care, and the doctor should not treat him unless he wants to make a gift of his services out of beneficence (as discussed in the previous case).

One must also recognize, however, that it is not easy for an individual to make provisions for obtaining medical care in the event that he is unemployed, since health insurance is usually provided through the work place and is far more expensive and less comprehensive when purchased independently.

Moreover, unemployment cannot always be avoided, nor can sufficient savings always be accumulated to provide for basic ne­cessities if unemployment occurs. Thus, the case can be made that there should be an organized system of social insurance to guarantee access to health care without excessive financial burdens for those who are unemployed. Thus, the physician's problem arises because the delivery system is inequitable.

If the patient is a six-month-old child with a probable ear infection, the analysis is different. That the patient is a child is an important difference because a child cannot take responsibility for providing for his own health care. What if the child's parents do not take the responsibility?

Society has traditionally recognized that the rest of us have obligations toward children whose parents are unable or unwilling to protect them from harm. Also, medical providers recognize an ethical duty to provide services immediately without regard to payment in emergency situations.

One way of handling this case is to say that the concept of "emergency" should be defined differently for a child than for an adult. If a child is in pain and sending the child to an alternate source of care would be a hardship, or if the parents might not get to the alternate source of care, with the result that the child would go without treatment and possibly suffer permanent health consequences, the case should be con­sidered an emergency. On this criterion, the six-month-old should be treated.

Such a policy clearly raises difficulties for providers. Emergency facilities always have the problem of covering the cost of care for patients who can't pay. The cost of emergency care for the indigent is distributed very unevenly across institutions, and those institutions that are most willing to accept the responsibility for the care of these patients then find themselves in the most severe financial difficulties.

A minor emergency center is in a somewhat different position from a hospital emergency department. Such a center has neither the hospital's historical tradition of community service to generate public expectations nor as much scope as the hospital for covering free care by raising charges to other patients. Nevertheless, I think neither type of facility should turn away the sick infant.

The owners of emergency facilities can vigorously pursue payment from the par­ents, establish a charity fund from donations to cover such patients, or seek public funds. They can attempt to educate parents about the availability of alternate facilities for future emergencies. They can advertise that care is not free and payment will be sought.

However, the better solution is at a societal level. The problem could be solved easily by guaranteeing payment for emergency care, broadly defined, for all children and spreading the cost equitably through a public system of taxes or compulsory in­surance premiums, in accord with ability to pay.

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