This transcript has been edited for clarity.
Hi. I'm Art Caplan. I'm the head of the Division of Medical Ethics at New York University Grossman School of Medicine in New York City.
An interesting item popped up, I believe it was on Reddit, where a doctor was asking an ethical question. There was a patient who — as many patients are these days — was not in a position to pay their medical bill.
He was a primary care person, a family doctor, and basically the patient said, "Look, how about we have an exchange? I'll clean your house as a way to pay off my bill. I work sometimes as a maid, and maybe I'll do that three, four, or five times over the course of the coming year, and then we'll be square. I don't have the cash. I don't have insurance. I would like to, if you will, barter or bargain some in-kind service." The doctor was wondering if this would be ethical.
In thinking about it and remembering different descriptions that were provided to me by doctors when I was working in states like Minnesota, where there was a heavy rural population, there's a long tradition of people paying doctors with services or with products that they agree upon. You'll find many of the old-time doctors saying that they used to get a fair amount of produce or sometimes meat. That would be brought in, and that was a way that people paid their bills in the past.
Even today — with many people facing severe medical debt and finding that it's hard to keep or get a job, or maybe their job is low-paying and they need that money for rent and to take care of their kids — there are plenty of people who still are trying to offer services. It's not only the lady who said to her doctor, "I'll clean your house."
I've seen and been told about people who will say, I can handle your publicity. I run a small operation that does social media, and maybe you'd like some free help in designing your website or getting a social media footprint that's much bigger. That's the modern version of "I'll bring in a couple of chickens or some eggs to pay for services."
I don't think there's any prohibition in medical ethics, that I'm aware of, that patients have to use cash or have to use insurance money to pay their bills. I think bartering is ethical. It may seem a bit unfortunate that we're in a position where many people don't have insurance coverage, or they don't get it through work, and they're facing debt that just would tip them over into bankruptcy if forced to pay their doctor's bills.
It's probably the case that this is a situation where some doctors are willing to do it. You don't have to accept those terms. I find it hard to imagine that there are going to be hospitals that say you can pay your bill through services or barter; more likely, providers, including doctors and maybe some nurses, may go this route.
Again, at its core, there is nothing unethical if the two parties agree on the exchange and that the service will cover the bill. The only problem I have with the house-cleaning situation is that I'm not sure it's good for the patient to be in the doctor's house. It may be that it's a little too intimate a connection in terms of what the patient knows about their doctor. It may feel somewhat coercive to have somebody cleaning the house in a way that isn't true when they bring you a bunch of eggplant or string beans.
It may be that people think it's just inappropriate to be put into a situation of more intimacy, but even there, I'm not sure that's a huge problem. It's just one that everybody has to agree on. Maybe the house gets cleaned when the doctor isn't home, or the doctor and their family aren't home. That's one way to handle that.
It may be that it's a small town where people know each other and there's not much secrecy or invasion of privacy anyway. That's just the reality of how it is in many rural places in America.
At the end of the day, I'm not sure if somebody said to me, Art, you want to give a speech and I'll make sure you can get a supply of eggs for the rest of the year, that that's compensation that I'd want to accept.
I do understand that's something that allows people to retain pride. It's an offer that sometimes seems absolutely acceptable in some situations. Again, there's no moral structure in any code of ethics or anything I'm familiar with that says you have to take the cash.
Bartering or bargaining, as long as it isn't exploitative and as long as it doesn't violate somebody's dignity and sense of self, I think is a way in tough times that the bill can get paid.
I'm Art Caplan at the Division of Medical Ethics at NYU School of Medicine. Thanks for watching.
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Cite this: Arthur L. Caplan. Bartering With Patients to Settle Medical Bills? Ethicist Says Yes - Medscape - Apr 09, 2024.
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