Medicine As If Justice Mattered:
One Doctor's Response

15 September 2004

“Medicine As If Justice Mattered: One Doctor’s Response” explores some of the fundamental questions of medicine and justice: 

  • Do physicians and other medical staff have a responsibility to serve the poor, even if the poor can’t afford it?
  • Should physicians have to perform public service in the wider community or, if not, should they have to shoulder the entire cost of their education (between one and one and a half million dollars)? Do health care institutions have the same responsibilities?
  • Beyond their roles in the direct provision of care, do health professionals have the responsibility to advocate within the larger society for social, political and economic changes serving the needs of the poor?
  • Is the lack of universal health care insurance in the United States properly considered injustice? Is the issue of injustice an issue for medical ethics to address?

In his Medical Center Hour talk, Dr. Hilfiker addresses these questions and others, such as: What do the poor and oppressed of the world have to offer the affluent? What did Mother Teresa mean when she said she sees the face of Jesus in the poor whom she served? Where can we find joy in joining the struggle for a more just world? What does all this mean to the struggling medical student or resident?

David Hilfiker , M.D., has served for over 20 years in inner-city clinics in Washington, D.C., working at Christ House, a medical recovery center for homeless men, and he cofounded St. Joseph’s House, a hospice for formerly homeless men dying of AIDS.

Dr. Hilfiker has recently written an account of his travels to occupied Iraq, under the aegis of the Christian Peacemaker Team (CPT). Click here to read his account. 

Following is an excerpt of a review of Dr. Hilfiker’s book Urban Injustice, How Ghettoes Happen : 

The 2000 U.S. Census shows that almost half (46.8 percent) of America's poor  are white; almost a quarter are Hispanic; 6.2 percent are Native American or Asian; just over a quarter (26.2 percent) are African American. Despite these statistics, poverty in the United States has become almost a code word for the inner-city black ghetto, with its crime and drugs. For Hilfiker, the essential causes of American poverty are primarily structural: the paucity of jobs on which one can support a family; inadequate access to health care and child care; meager educational resources in inner cities; the workings of the criminal justice system; and, for African Americans, a painful history of slavery, segregation and discrimination.

The U.S. poverty index greatly understates the amount of genuine poverty. Government statistics have reckoned it, for half a century, by taking the cost of a minimally adequate diet and multiplying by three. In official government calculations, the term poverty level usually refers to the amount of money a family of four would need to stay out of poverty. In 2000, that figure was $17,650. Many economists estimate that in reality, a family of four needs to be at 150 percent of the poverty level to survive. For in the past half century, the costs of items in the family budget other than food—utilities, housing, transportation, child care, health insurance—have skyrocketed.

Dr. Hilfiker is especially sensitive to the causes of poverty in African American inner-city ghettoes. Good-paying blue-collar manufacturing jobs have evaporated. Inner-city black incarceration rates are staggeringly high. Roughly one out of every three black males between 18 and 34 years of age was under the active supervision of the criminal justice system: under arrest, awaiting trial, awaiting sentencing, on probation, in jail or prison, or in half-way houses or other mandated programs or on parole. Even black entrepreneurs seem loath to hire ghetto youth or the formerly imprisoned.

Our welfare system seems stunningly stingy when compared to all other advanced industrial nations . . . As the Children’s Defense Fund puts it . . . “on any given night 562,000 children go to bed hungry.”

Dr. Hilfiker’s prescription for ending poverty as we have known it involves one new program: universal health coverage, which he argues persuasively, would save us as a nation on present health costs and still incorporate the 43 million presently uninsured. The special-interest lobbying of insurance companies, however, makes this unlikely. He would expand three other existing programs: the earned income tax credit, which economists have shown to be the most successful current program for raising families out of poverty; unemployment insurance, which he would expand so that it would dispense enough income to keep the unemployed at least at poverty level; supplemental security insurance for the disabled. Hilfiker notes, “As a physician, I sometimes struggled for years to get examiners at S.S.I. to understand that one or another of my patients was, indeed, disabled.”