I recently shared with some of my fellow therapists that I was thinking about coming in to work pro-bono on the weekends to treat low-income clients. To my shock, they all told me that would be unethical.
My fellow therapists stated these clients would feel “less than” by being relegated to an “undesirable” timeslot and not enjoying the same benefits and options as other clients who can pay.
I countered that I once worked at a drug and alcohol rehab center at which a dentist donated hundreds of thousands of dollars in free dental care to the patients if they came to see him on the weekend, outside of his normal hours. I asked my fellow therapists if this was unethical and to my chagrin, they replied it was. So extreme was their commitment to equality that they felt it would be better for the dentist not to treat these patients at all—even to leave them in chronic physical pain— rather than to exclude them from being seen during the week with the rest of his patients.
As a person who grew up on government assistance with a single mother with disabilities, I know what it means for people to financially struggle and to experience sub-par healthcare systems. I remember for example accompanying my mom to a Medicaid appointment and being surprised at the low quality of care she received in comparison to me (she prioritized me over herself and made sure I had private insurance). It would have meant the world to my mother if a private practice provider said, “Although it may not be perfect, I can give you much better care than this if you’re able to come see me this weekend.” I know many people who receive care through Medicaid or the VA who would agree.
History has taught us that ignoring the self-determination of autonomous human beings leads to injustice. A more powerful group deciding what is supposedly in the best interests of vulnerable people over their objections has never worked out. I fear that has become the case in healthcare, where the wishes of a client can be so easily superseded by the consensus of a more powerful group of people.
I think one fundamental flaw in the current landscape of healthcare ethics is that “equality” is being confused with “equity.” The stark reality is that healthcare is unequal. Life is unequal. If we ignore that reality, we refer low-income clients elsewhere and still feel a sense of self-satisfaction about how equally we treat our privileged clients who remain. But this creates a two-tier healthcare system and makes those inequalities worse. Treating clients as autonomous, unique individuals demands that we abandon one-size-fits all policies and sometimes accept a little inequality in order to bring about equity.
While I want to be clear that I will continue to follow legal and ethical guidelines unless and until they are properly emended, I think justice demands that some of these rigid rules need to be reviewed and changed. For example, it’s widely known that medical insurance companies pay therapists rates that are far below market, often less than half of the therapist’s customary charge. Maybe a therapist would be willing to accept medical insurance and that reduced rate in order to provide treatment to low- and middle-income clients.
But here’s the trap of equality vs. equity again: if a therapist accepts medical insurance and its vastly reduced rates, they must do so for all of their clients, including the wealthy ones. As a result, many therapists simply don’t accept medical insurance at all. I wonder how much more mental health service would be provided to the public if therapists were free to accept these reduced medical insurance rates from lower income clients but charge their full rate to those able to afford it.
This rigidity applies to many aspects of therapy (and healthcare in general) beyond just financial considerations. For example, can therapists say with certainty that in every single imaginable case, a legally mandated report prompting police intervention in a family is always in the interest of a child? Maybe therapists need to have some latitude to exercise their professional judgement and treat clients as individuals instead of defining them by their circumstances.
When modern democracy was being formed, political scientists coined the phrase, “tyranny of the majority.” I wonder if many systems of professional ethics are just this tyranny cloaked in the guise of concern. In ethical discussions, when I hear vague and judgmental words like, “professional” and “appropriate” they seem more like a mechanism for the speaker’s biases to be legitimized than for the implementation of some objective noble value. This is, of course, unconscious as many therapists simply take for granted that their ideas of these terms are the correct ones. But it is tyranny nonetheless.
At the same time, laissez-faire healthcare without any accountability would be equally destructive. I wonder then, can we create systems of ethics that balance flexibility with standards? I think there are examples in history. For example, in the common law system of our courts, judges are often called upon to decide questions of law. This differs greatly from how courts function in much of continental Europe, for example, where Roman and Napoleonic influences have led to courts simply applying existing legal statutes to cases.
Perhaps socioeconomic and cultural humility, equity, and justice itself demand the end to professional ethics as we know them. It could simply be that strict codes of ethics may be inherently unethical if individuality and personhood are to be taken into account.
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