On this side of the pond in the United States, it is a familiar refrain.Patients being asked to prove that they can afford the cost of a surgery and/or any post-operative medications. A recent Kaiser Health News article caught my attention a few months ago as it outlined multiple cases of solid organ transplant candidates being asked to show sufficient monetary assets before receiving their organ and post-operative immunosuppressive drugs. Failing to provide the necessary financial proof results in, very simply, a denial of your transplant. Or a gentle prodding to go and ‘actively fundraise’ in order to meet the anticipated expenses. Which is what many patients end up doing. In fact, about one-third of campaigns on GoFundMe are related to healthcare needs .

In cases where there is a finite amount of the resource (ie kidneys, livers and hearts) and where more than 114,000 people are waiting for organs and fewer than 35,000 organ transplants were done last year, this is a prickly situation. One side of the argument is that these precious commodities are in short supply and if we know in advance that someone can’t afford a lifetime of immunosuppressive drugs, the chance of that organ being rejected is a virtual certainty. And if that organ is rejected, well, it can’t be used again. And it might have gone to a recipient who potentially would have benefited from it for years to come because that person would have been able to afford its ‘cost of maintenance’. It is not an illogical argument.

But isn’t this a slippery slope? Don’t we risk making this argument a crutch to deny care to a population cohort that is impacted the most? We already know that income is directly tied to healthcare inequality and can be a major limiting factor in access to care. Situations like the ones described here simply perpetuate the problem. We’re effectively auctioning organs to the financially stable. Is this what we want for the most vulnerable and sick in our society? We tell ourselves that we are not using financial stability as a gateway to care, but we are. We insist that this is a rational decision rooted in some sort of clinical- benefit credo. It goes something like this: why make someone undergo an invasive and complicated solid organ transplant, knowing full well that the patient will ultimately face organ rejection which could lead to further downstream sequelae, not to mention the stark reality of having lost an organ. Knowing that this patient cannot afford the medication required for this condition, perhaps someone else can benefit from this organ. In a nutshell, that’s how we rationalise it. This is the clinical benefit mantra that we repeat to ourselves.

We don’t deny care to people when they choose an unhealthy lifestyle. We still provide lung transplants to smokers and liver transplants to heavy drinkers. We don’t tell individuals with a sedentary lifestyle or a bad diet that they cannot have a coronary stent. You see, it would be wrong to assign blame and deny care to patients based on the lifestyle choices they make. Some of us might want to. But we don’t. So why, then, is it ok to deny care to patients based on their lack of income? Nobody wants to be poor. No one wants to get sick and then be unable to afford medication. This is not something that we aspire to. It has become acceptable to do this because money drives a disproportionate amount of the healthcare decisions in the United States and, to be fair, elsewhere as well. If it didn’t, I wouldn’t be writing this column on this very subject because the scenarios that I describe would have never happened. But where do we draw the line? Is it ok to ask about a patient’s financial stability for non-emergency treatments? Or non-life-threatening situations? Or perhaps in chronic disease states but not acute?

How about, never. It is never acceptable to ask patients if they can afford their healthcare, or use their lack of financial stability as a means to preclude access to care. When people are ill and facing gut-wrenching decisions, the last thing they need is to think about catastrophic health spending for decades to come and the demonstration of financial solvency. It is an idealistic point of view. But someone has to be an idealist.