"To Do the Necessary..."

English as spoken in Kenya has many interesting and sometimes confusing phrases (or at least confusing to American ears), but more often than not, these "Kenyanisms" are right on target.

A couple of days ago Dr. Serrem was musing out loud about a certain patient and whether we would "do the necessary" (as opposed to an alternative course of action). Sounds like another version of Kant's categorical imperative, which in a way I suppose it is.

The context was this: "unknown African female" in her twenties, admitted after the motor bike she was riding (along with two others) crashed. (I am told these kinds of accidents have become distressingly common in recent years.) She suffered a broken femur, multiple facial fractures, as well as a head injury which rendered her unconscious. Eventually, she woke up, but still could not tell us her name; the families of the other two victims claimed to have no idea who she was.

So when Dr. Serrem was wanting to "do the necessary" he was talking about surgery to properly repair her fractured femur. Just the needed hardware (a K nail) would cost more than $200, and then another $200 for the surgeon's fee. Her total bill could easily end up being $700 or $800, with no guarantee that the hospital would ever get paid. Hence the dilemma: "do the necessary" for the patient and accept the likely financial hit to the hospital; or find some alternative.

In my many years as chairman of our hospital ethics committee in the U.S, we have sometimes faced difficult dilemmas; but in a large hospital with a healthy bottom line, I can honestly say that financial issues have never played more than a peripheral role in those decisions. In the U.S., we have the great luxury of being able to divorce ethics from finances. (Perhaps it would be more accurate to say that our wealth has allowed us to pretend that the two could be divorced, but with the Medicare trust fund due run out of money in seven years, perhaps we have only postponed our own day of financial reckoning.)

But this is not an abstract issue here. Several years ago, the Friends Lugulu Hospital was in financial extremis, unable to even pay its staff for several months running. Even now, the finances are strictly month-to-month. We cannot afford to take too many chances on patients being unable to pay. As I have often said, Lugulu is a mission hospital, but it is not a charity institution. It gets no outside support for day-to-day operating expenses, but depends entirely on fees paid by patients to keep operating. True, many patients are for legitimate reasons unable to pay in full, and their bill will be adjusted accordingly. But to put it bluntly, too much free or charity care could easily sink the hospital. And although the amounts in terms of dollars seem small to us, in the context of the local economy, fees like this can be the equivalent of several months income for many families.

The end of the story: the doctor and the administrator went back and forth over the weekend (they both were undecided), before the family was finally located on the fifth day. They paid some but not all of her $100 bill, and insisted on taking her to the nearby government hospital in town, where the daily charge will be considerably less -- but where she is very unlikely to get the needed surgery for her leg. The family's decision saved the hospital from having to make the difficult choice, but unfortunately the woman is likely to suffer more as a result.