The Moral Dilemma of Learning Medicine from the Poor

By Rachel Pearson, MD, PhD

If we had a big sack of money

My mentor Susan McCammon taught me how to tell a person that she is going to die for lack of care. You say something like this:

Student-run clinics — the places of last resort

My fear, as Congress debates the American Health Care Act (AHCA), is the same fear the American Medical Association has: Under the AHCA, millions more Americans will lose insurance coverage.

No apparent distress

My book, No Apparent Distress: A Doctor’s Coming-of-Age on the Front Lines of American Medicine, relates the true stories of the students, doctors, and patients at St. Vincent’s and the other places where I was privileged to train: Texas prison hospitals, public hospitals, and a border clinic where patients would wade across the Rio Grande to see a volunteer doctor.

Learning on the poor

Indeed, one of the reasons I wrote the book was because I had become increasingly distressed by the ways that I, as a student, benefited from the unequal distribution of medical resources. As a student, I did things to my uninsured patients — endometrial biopsies, minor surgeries, the delivery of diagnoses of cancer — that I would never have been allowed to do to an insured patient. I learned good skills because I was allowed to practice on people who had no other option.

Trainees benefit directly from denial of care

But because we trainees also benefit directly from the denial of comprehensive care to large swaths of American society, the situation is morally complex. The physician-researcher Merle Lenihan describes charity as a “moral safety valve” —

Charity is critical. But charity is not enough.

Charity is critical. But charity is not enough. Because most physicians do not own the medicines, operating rooms, and infusion centers that our care requires, there are life- and death-defining limits to what our charity can do.


  1. Harriet A. Washington, Medical Apartheid: The Dark History of Experimentation on American Blacks from Colonial Times to the Presents (New York: Penguin Random House, 2008).
  2. Smith S, Thomas R, Cruz M, Griggs R, Moscato B, Ferrara A. Presence and Characteristics of Student-Run Free Clinics in Medical Schools. JAMA. 2014;312(22):2407–2410. doi:10.1001/jama.2014.16066
  3. Paul Starr, The Social Transformation of American Medicine. (New York: Basic Books, 1982) 171–172.
  4. Merle Sharber Lenihan, Charity in Health Care: Safety Net or (Moral) Safety Valve? (dissertation: University of Texas Medical Branch, 2013).

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