Four years ago today, the federal government began its rollout of the US Patients’ Bill of Rights as part of the Affordable Care Act. Now patients have rights, although not necessarily the ones they need. Meanwhile, health care workers have none.
As a psychiatrist in a large urban hospital in a drug-ridden neighborhood across the street from a homeless shelter, I’m often called upon to assist when patients’ behavior is troublesome to the staff. Conflicts between health care workers and staff are a daily occurrence. Many patients intimidate staff with verbal threats, sexual harassment, and actual violence. Others refuse to leave the hospital after they have been released.
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When confronted about their behavior, patients often insist that they know their rights. In the nurses’ stations, I hear hospital staff mutter, “What about my rights?”
In fact, it’s dangerous to be a health care worker. A 2006 study in the Journal of Emergency Medicine reported that 67 percent of nurses and 51 percent of doctors in surveyed emergency rooms were physically assaulted during the six-month study period, and nearly 100 percent were verbally harassed.
Recently, I was asked to see a patient who had just threatened to beat up a nurse if she didn’t get a sandwich for herself and her husband. I listened to the couple’s complaints and asked them if we could agree that it was not okay to threaten hospital staff. They replied that it was not acceptable that they were hungry, had had to ask for food so many times, and had not gotten any.
Particularly in the emergency room, where this incident occurred, desperate patients frequently come into conflict with hospital staff, which cannot possibly meet everyone’s needs at once. The patient and her husband felt that their rights had been violated, and that they had no recourse but to violate the rights of others.
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The federal Patients’ Bill of Rights takes a business-oriented, customer-service approach to health care. It highlights issues such as services provided, consent to and refusal of care, and billing — in other words, contractual arrangements. From that standpoint, the patient probably does have a right to receive a sandwich in a timely manner.
Not spelled out in the regulations, however — as is clear from the example above — is the protection of either patients or caregivers from harm. The patient who has injured a staff member has not enjoyed a right to health care. The beleaguered health care worker has not experienced the safe workplace to which she is entitled.
The truth about health care is that it evokes intense feelings due to its life-and-death nature, and the powerful transferences triggered in the doctor-patient scenario. Far from relating as parties to a contract, patients and health care workers can hate each other enough to kill — and fear each other enough to carry weapons. On July 24, a client shot his case worker to death at the Mercy Fitzgerald Hospital campus near Philadelphia. The client’s psychiatrist pulled out his own weapon and shot the murderer, his patient.
Patients’ rights, with their emphasis on health care as a business transaction, contribute to the mindset that patients and doctors must be vigilant, even paranoid, in protecting their interests. That mentality reached its bizarre apotheosis in the shooting at Mercy Fitzgerald, where the psychiatrist was the last man standing.
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In contrast, human rights are identified by their “inalienable” quality; they derive from the acknowledgment of our human dignity, freedom, and need for personal security. A human rights perspective offers a solution that respects the dignity of all participants in a health care setting. The Open Society Foundations has advocated applying principles of human rights to medical settings. The group’s focus has been on oppressed peoples, such as Roma women subject to forced sterilization, but US hospitals can also benefit from a human rights-based approach.
How might a human rights perspective have changed the emergency room encounter between the patient and her nurse? To begin with, identifying unacceptable conditions as human rights violations has the power to galvanize administrators and lawmakers into addressing issues such as crowding and starvation of needy patients in the emergency room. Open Society Foundations refers to this as “shaming power.” Shame in health care should shift from patients, where it currently resides, to policy makers and profiteers, who bear responsibility for our current inadequate health care system.
As to health care workers, The Journal of Emergency Medicine study noted that fully 65 percent of subjects who had been assaulted never reported the incident to superiors. Workplace violence should never be considered an unfortunate part of the job; it’s an abuse of the worker’s liberty and security. The human rights perspective acknowledges that health care workers have the same inherent rights to safety as do patients. The health care worker is encouraged to report, document, and demand response from the institution and the government to prevent violent and threatening behavior.
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When dignity, liberty, and security are appreciated as the basis of the right to health care, conflicts between patients and health care workers will occur less frequently. Until then, it’s us versus them.
Dr. Anne Skomorowsky is a psychiatrist at Columbia University and a Public Voices Fellow with the OpEd Project.