Tales From the American Medical System

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Epistemic Sta­tus: Over­heard in New York

I am walk­ing and talk­ing with my friend, a Type I Di­a­betic, when he re­ceives a phone call from his doc­tor’s office.

As a Type I Di­a­betic, my friend needs in­sulin. The effects of not hav­ing in­sulin are very bad, and in­clude death.

He has run out of re­fills on his pre­scrip­tion, and will run out of in­sulin on Satur­day. He called about a week ago to at­tempt to rem­edy this situ­a­tion and get re­fills.

That’s for back­ground. This isn’t about the or­der of mag­ni­tude higher my friend’s co­pay is in Amer­ica, com­pared to the en­tire re­tail price in Canada.

This is about my friend’s at­tempt to get le­gal per­mis­sion to con­tinue buy­ing life-sav­ing med­i­ca­tion for a lifelong con­di­tion with no known cure.

Be­cause for some rea­son, in Amer­ica you need le­gal per­mis­sion to buy it, and you need to re­new that pe­ri­od­i­cally, de­spite there be­ing chance of the need for said life-sav­ing medicine go­ing away.

I over­heard the phone call from my friend’s end. The rest is filled in based on a com­bi­na­tion of talk­ing to him af­ter, and ex­trap­o­la­tion. He has re­viewed this for ac­cu­racy.

The nurse tells my friend he needs to go see his doc­tor, be­cause it has been seven months, and the doc­tor feels he should see his doc­tor ev­ery three.

My friend replies that he agrees he should see his doc­tor, and he has made an ap­point­ment in a few weeks when he has the time to do that.

The nurse says that he can’t get his pre­scrip­tion re­filled un­til he sees the doc­tor.

My friend ex­plains that he does not have the time to drop what he is do­ing and see the doc­tor the next day. That he is happy to see the doc­tor in a few weeks. But that un­til then, he re­quires in­sulin to live.

The nurse says that he can’t get his pre­scrip­tion re­filled un­til he sees the doc­tor. That if he wants it ear­lier he can find an­other doc­tor.

My friend ex­plains again that he does not have the time to see any doc­tor the next day, nor can one find a doc­tor on one day’s no­tice in rea­son­able fash­ion. And that he has already made an ap­point­ment, and needs in­sulin to live. And would like to speak with the doc­tor.

The nurse re­fuses to get the pre­scrip­tion filled. The nurse does not offer to let him speak to the doc­tor, and says that he can ei­ther wait, make an ap­point­ment for the next day, or find a new doc­tor.

My friend points out that with­out in­sulin, he will die. He asks if the nurse wants him to die. Or what the nurse sug­gests he do in­stead, rather than die.

This seems not to get through to the nurse, be­cause my friend asks these ques­tions sev­eral times. The nurse does not offer to re­fill the pre­scrip­tion, or let my friend talk to the doc­tor.

My friend says that if the doc­tor does not give him ac­cess to life sav­ing medicine and in­stead leaves him to die, he will post about it on so­cial me­dia.

The nurse now de­cides, for the first time in the con­ver­sa­tion, that my friend should per­haps talk to his doc­tor.

The doc­tor calls a few min­utes later. The doc­tor is quite up­set about this threat to post on so­cial me­dia about be­ing de­nied ac­cess to pur­chase life sav­ing medicine.

The doc­tor ac­cuses my friend of hav­ing a gun to his head. My friend points out this is a rather in­ter­est­ing choice of metaphor. One could say that the doc­tor has a gun to his head, in the form of deny­ing him ac­cess to life sav­ing medicine. And that the two do not seem re­motely com­pa­rable.

This seemed right to me, as I had used ex­actly the words ‘gun to your head’ when dis­cussing the situ­a­tion with my friend be­tween the two phone calls.

I was not refer­ring to the pos­si­bil­ity of posts ap­pear­ing on so­cial me­dia.

The doc­tor goes over de­tails of my friend’s care. He wants my friend to come in.

My friend agrees. Points out he already made an ap­point­ment. That he needs in­sulin to live.

The doc­tor asks, what if your sug­ars are high?

My friend points out that if this were the case, he would still need in­sulin to live.

The doc­tor keeps ask­ing my friend to come see him. My friend keeps point­ing out he has already agreed to do this.

The doc­tor con­tinues to ad­mon­ish my friend for his blame­wor­thy be­hav­ior of only do­ing all the things he’d been asked seven months ago to do, of only see­ing sev­eral other spe­cial­ists for tests, rather than also see­ing this doc­tor ev­ery three months as a good obe­di­ent pa­tient prop­erly con­cerned for his own health would have done.

My friend points out that re­gard­less of all that, he would still need in­sulin to live.

The doc­tor then ad­mon­ishes my friend for his ter­ribly blame­wor­thy be­hav­ior of not be­ing aware he had run out of re­fills. Clearly, my friend should have tracked that. My friend points out that he doesn’t keep the pre­scrip­tion boxes, he keeps the vials. That few pa­tients know, no mat­ter what they in the­ory ‘should’ know, how many re­fills they have left on a re­li­able ba­sis. And that he had re­al­ized all this a week ago and called his doc­tor, but was only now hear­ing that the re­fill wasn’t go­ing to be forth­com­ing. Also, to para­phrase a bit, he asked the doc­tor: Why the hell is it go­ing to run out at all, any­way? Are we ex­pect­ing a cure real soon now? This need for in­sulin to live isn’t go­ing to go away.

Hav­ing prop­erly pointed out all the ways my friend was bad and should feel bad, the doc­tor now claims that the nurse was never told that the doc­tor wasn’t go­ing to re­fill the pre­scrip­tion with­out my friend com­ing in first.

My friend points out that the nurse did in fact say ex­actly those words. That the pre­scrip­tion would not be re­filled with­out a visit first.

What the doc­tor then claimed he said to the nurse was rather that the doc­tor did not want to re­fill the pre­scrip­tion. That the doc­tor would pre­fer that my friend come in.

This is stan­dard im­plicit com­mand de­ni­a­bil­ity. Pure gaslight­ing. It’s the same as when a mafia boss says it would be great if a cer­tain some­one wasn’t seen round these parts some time soon. Or when the CEO re­marks that peo­ple seem to be us­ing too many va­ca­tion days. The nurse’s job de­pends on en­forc­ing the im­plied or­der given by the doc­tor.

The doc­tor asks why my friend is be­ing so un­rea­son­able. My friend points out that he started with an en­tirely and un­ques­tion­ably rea­son­able po­si­tion of agree­ing to come in at his next available time in ex­change for con­tinued ac­cess to life chang­ing medicine.

That he’d only changed to what the doc­tor was char­ac­ter­iz­ing as the un­rea­son­able po­si­tion of ‘if you deny me life sav­ing medicine I might tell peo­ple that you did that’ when it was clear that un­til he threat­ened that, he was go­ing to be de­nied life sav­ing medicine.

If any­thing, the origi­nal po­si­tion seems to me like it points out that the sys­tem has given some­one the power to threaten to with­hold life sav­ing medicine, that they agree the per­son needs, in or­der to co­erce the be­hav­ior they want from the other per­son. Which seems bad. But hey.

After a num­ber of min­utes of such ad­mon­ish­ments, my friend hav­ing been suffi­ciently in­ter­ro­gated and ad­mon­ished for his das­tardly non-sub­mis­sive, non-com­pli­ant role, and his un­will­ing­ness to drop ev­ery­thing in his life on a dime for no rea­son, the doc­tor offered to re­new the pre­scrip­tion for long enough to make it to the ap­point­ment. Thus al­low­ing my friend, for the low low co-pay price of ten times what it costs in Canada, to legally pur­chase the life-sav­ing medicine he will need pe­ri­od­i­cally for the rest of his life.

In some ways this was the good sce­nario. In the end, ac­cess to life sav­ing medicine was in fact re­newed. And this was what hap­pened when my friend had, he in­sists, an un­usu­ally con­scien­tious doc­tor, who is us­ing his pow­ers of co­er­cion, via the threat of with­hold­ing life­sav­ing medicine, en­tirely to en­sure the health of his pa­tients, and who was in the office and ca­pa­ble of re­spond­ing promptly.

Ladies and gen­tle­man, the Amer­i­can med­i­cal sys­tem.