Art of Medicine
Feb 2021

Not Yet Sick Enough to Qualify for Care

Christopher Hamblin Schifeling, MD
AMA J Ethics. 2021;23(2):E198-200. doi: 10.1001/amajethics.2021.198.


This drawing portrays 3 perspectives on deliberate emergent dialysis for undocumented immigrants with kidney disease and invites a viewer’s reflection on health equity for this clinically and politically vulnerable group of patients.


Figure. Hydra



Pen, paper, Microsoft Word.


Dialysis can be scheduled or emergent. For patients of privilege, it is scheduled regularly as a maintenance therapy to treat their end-stage kidney disease so they do not become acutely ill. For undocumented immigrant patients in the United States, however, dialysis is most often done emergently, since US-based health policy confers on them a right to care (due to variations in states’ Medicaid coverage policies) only when they are so ill that they would die without dialysis. The phrase deliberate emergent dialysis is used to call attention to the inhumanity and inequity of an approach to patient care by which we clinicians stand by, waiting for patients in need to become sicker, sicker, sicker, until we deem them sick enough to help.

Much of modern medicine’s power has sprung from insights of pathology, which uses different microscopic stains to reveal otherwise hidden knowledge of diseased tissue. Understanding social ills that plague the United States will similarly require myriad “stains” to reveal the full scope of these problems in health care alone.

This drawing develops 3 such “stains” by which to view clinical and ethical dimensions of the problem of deliberate emergent dialysis.

  1. By numbers. A set of statistics from a peer-reviewed article presents the scope of this problem in terms of the number of undocumented patients with renal disease, the number of states not covering scheduled dialysis for patients in need, the net savings gained were dialysis to be scheduled instead of emergent, and the number of patients needed to receive scheduled dialysis for a year to save the life of an undocumented patient with end-stage renal disease receiving only emergent dialysis.
  2. By letters. The “one-liner” on patients and their conditions as it might be recorded in health records emphasizes how care can be experienced as fragmented and remote by both end-stage renal disease patients and their clinicians.
  3. By ciphers. A poem offers images of what it might mean for undocumented patients to be without, without, without.

Like the many-headed Hydra of Greek mythology, patients undergoing deliberate emergent dialysis experience suffering that is preventable.


AMA J Ethics. 2021;23(2):E198-200.



Conflict of Interest Disclosure

The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.