By Edward Jung (PO ’22)
Developing a concrete definition for the relationship between a doctor and their patient is a difficult question whose answer lies within the intersection of medicine, ethics, and the law. Medical students are taught in medical school that their primary obligation is to patients; yet, from the Hippocratic Oath to Hollywood’s representations of physicians feeling this obligation toward antagonists, the real-world definition of a patient is a complex legal question with hard-hitting implications. During this global pandemic, understanding the legal history of defining the patient-physician relationship sheds light on the health inequalities faced by critical American communities and raises questions of ambiguity and obligation.
The legal history of establishing the patient-physician relationship details a long history of looking at the specifics of situations to consider liability under the law. Hurley v. Eddingfield in 1901 underlined the importance of acceptance of terms in treatment. Childs v. Weis highlighted that “a physician is not to be held liable for arbitrarily refusing to respond to a call of a person even urgently in need of medical […] assistance provided that the relation of physician and patient does not exist.” Mead v. Adler held that: “in the absence of an express agreement by the physician to treat a patient, a physician’s assent to a physician-patient relationship can be inferred when the physician takes an affirmative action with regard to the care of the patient.”
Generally, as both Hurley v. Eddingfield and Childs v. Weis demonstrate, states often differ in their definitions of the patient-physician relationship, but physicians are largely not under an obligation to treat unless they actively choose to. Barring emergency/discrimination exceptions, an affirmative action, indicating the voluntary start of service by a physician as in Mead v. Adler, will begin the formation of the relationship. As a consensual entrance, this relationship is really a legal contract formed in which the physician owes a duty to that patient to continue to treat or properly terminate the relationship.
Healthcare inequality has long been an issue plagued by significant disparities in cases between the poor and the rich. Many low-income families tend to have poorer health due to geographical disparities in care, rising costs of healthcare, and lack of access to health insurance. Furthermore, because poor health can lead to poverty due to the pressures of maintaining high-paying jobs while ill, healthcare inequality disproportionately affects low-income communities with a negative feedback loop that is difficult to break.
In light of the escalating COVID-19 pandemic, the United States has faced a series of policy-driven difficulties with immigrant access to healthcare. Using the framework of the physician-patient relationship and its legal praxis, one can consider the issues at the heart of immigration and healthcare to be deeply worrying. If we consider the U.S. government to have an obligation as the “physician” to a harrowed immigrant population, while there may not be an “express agreement” designating such as in Mead v. Adler, the government’s misleading and problematic policy definitions ought to be viewed as affirmative actions. Silence and inaction are harmful to the immigrant communities of America and our healthcare policies should reflect an obligation to the health of the people, and the health of the nation. This is especially more pronounced during trying times like these.
The increase in immigration enforcement around the country is a direct cause of fear among many undocumented immigrants, and even though Immigration and Customs Enforcement (ICE) announced it would slow civil immigration enforcement actions during the pandemic, there have been reports suggesting the opposite, stressing that Trump’s policies are putting vulnerable immigrants at risk as the virus spreads. Within a physician-patient relationship that one might think of in their head, fear is likely the last thing they would expect. An element of care in a medical sense, without any legality, is a genuine interest in healing; fear being used as a tactic of power and dominance in the U.S. is a significant deterring factor to a proper restoration of just and equitable healthcare reform.
After the “public charge” rule change, which penalizes immigrants who have used public assistance (i.e. Medicaid), went into effect on February 24, 2020, misinformation caused a significant chilling effect on healthcare utilization. Many immigrants disenrolled their U.S. citizen children from Medicaid in fear of over-relying on public assistance under the new rule of law and being unable to adjust immigration status as a result.
People and community-driven health assurance both mean little when they are discussed in an America with anti-immigrant policies in place. The irony of millions of undocumented immigrants without health insurance getting free coronavirus testing through the Families First Coronavirus Response Act, yet not having coronavirus treatment covered, is a disappointing slap in the face to a modern conception of what a proper healthcare system, rooted in the ideals of a Hippocratic physician-patient relationship, should look like.
Silence is inaction, and even worse is an implemented policy change as in the “public charge” rule that leads to misinformation and health inequality. This is not an issue of immigration or legality; this is an issue of our shared humanity. Considering the legal history of the physician-patient relationship in America offers a deeper understanding of the vantage points from which one could question the treatment of immigrant communities by the U.S. government. Silence is not just inaction, rather, it is an affirmative action that activates the physician-patient relationship, a relationship the U.S. ought to recognize and operate.
There are many potential solutions, and they are especially crucial to a sound public health. Limiting immigrant coverage to COVID-19 puts many more communities at risk, and the pandemic offers us a comprehensive, real-time case study of the dangers associated with ignorance and avoidance of key healthcare issues. Improving definitions in Medicaid and ambiguity in healthcare policy are a must, as legal history and ramifications alike can significantly affect climates of fear and distrust. Social improvements for communities most struck by health inequalities are also key to long-term solutions, so that these climates themselves can have root cause fixes. Moving forward, solutions must be multi-faceted, encompassing spheres of the law, healthcare, and our shared humanity. The coronavirus pandemic has come at a crucial moment in American history where there is a wariness of public health authorities and care, and positive affirmative action from the federal government is paramount in the forward-moving resolution of this trust-rebuilding.