Holding the dead hostage

JD LUMAIN, 42, was a hiker and team leader at Convergys who collapsed in Baguio City after climbing Mount Pulag on Dec. 10. Following what was later diagnosed as a heart attack, he was rushed to a hospital where he underwent angioplasty, received treatment in an ICU, and showed signs of recovery. But later he succumbed to multiple organ failure and died after spending nine days in the hospital.

The bill amounted to more than P600,000. Unfortunately, due to the unpaid amount of P475,000, the hospital wouldn’t release his death certificate and thus the family couldn’t bring his body down from Baguio for a proper wake and burial. Lacking the necessary funds, JD’s family and friends made appeals for support on social media, but still couldn’t raise enough money.

It was only three days after JD’s death—upon the provision by his company of a guarantee—that the death certificate was released, the transfer permit granted, and his body finally brought home to Manila.

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The Lumain family is not alone in enduring such an ordeal. Kristina Misajon, whose mother succumbed to tongue cancer in November, wrote of the “humiliating experience” of pleading with officers of a private hospital to release even just a photocopy of a death certificate—a requirement for cremation. She lamented: “They would not believe that my mother, an OFW of 15 years, spent all her savings battling cancer… They would not believe that we had no properties, nothing to provide them as collateral.”

The funeral parlor eventually agreed to the cremation even without the certificate, but at the time of this writing, the family has yet to receive the death certificate, effectively preventing them from moving on—i.e., getting benefits or making claims from the Overseas Workers Welfare Administration, Social Security System and Pag-Ibig.

Republic Act No. 9439, passed in 2007, actually stipulates: “In case of a deceased patient, the corresponding death certificate and other documents required for interment … shall be released to any of his surviving relatives requesting for the same.” Curiously, however, the law specifically mentions that “patients who stayed in private rooms shall not be covered in this Act.” In effect, this law allows the withholding of documents from a vast majority (though this remains, to my knowledge, a legal gray area). And as we have seen, the withholding of a death certificate is, at least in some cases, tantamount to holding the dead hostage, since it is required for the transport, cremation or burial of the dead.

We should understand, however, that for private (and even public) hospitals, holding on to patients or their papers is the only realistic way to collect bills. Hospitals, too, have to make ends meet (i.e., pay for equipment, medicines, operational costs, and staff) and in reality, very few people actually own up to their promissory notes. As one physician told me: “I don’t know how the hospital ensures that it will not go bankrupt other than to hold on to the death certificates.” Thus, while at the level of individual cases it may sound like a commonsensical act of charity to let patients and papers go, writ large, this is an unsustainable policy that is unfair to the hospitals and the doctors, many of whom do their very best for their patients.

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In many countries, there are safety nets for “catastrophic illnesses” (i.e., conditions that have grave medical and financial consequences). In Thailand, for instance, a universal health care (UHC) system, financed by SSS-style contributions and tax revenues, provides everyone with comprehensive health insurance. Since the system pays hospitals directly, there is no need for them to hold patients or withhold papers.

The Philippines, too, has attempted to move toward UHC, with PhilHealth as a key vehicle. To its credit, PhilHealth has attempted to address catastrophic illnesses through its Z-benefit package, launched in 2012, which offers fixed-rate benefits for certain conditions (i.e., P550,000 for coronary artery bypass surgery). However, it covers only a limited number of diseases—and a limited number of hospitals. Moreover, even with this coverage, expenses in the final days of a patient’s life can well exceed these allotments, given, among many other factors, the impulse to do “everything” to save a patient’s life and the inherent high cost of life-prolonging machines and therapies. Thus, many Filipinos continue to have little or no protection from catastrophic illness, and families often end up burdened both by the loss of a loved one and financial ruin.

For their part, many health care providers are disgruntled by the inefficiency and delays in getting reimbursements, making them lukewarm to the idea of UHC.

There are no easy solutions to these problems. At the least, however, we need a stronger law that gives due dignity to the dead, who deserve proper interment and burial. The provision that prevents patients in private beds from being accorded this right must be removed.

But we also need to be fair to hospitals: They have to be given their due for services they provided. This is why we must push for a system that relieves financial burden from patients and provides payment to—while demanding accountability from—hospitals: one that allows families and health care providers alike to focus on the primary business of healing, caring, and providing comfort.

Ultimately, universal health care is the ransom we must pay to bring back dignity to the dead, comfort to the bereaved, and sanity to a health care system that badly needs reform.

Gideon Lasco is a physician and medical anthropologist. Visit his website on health, culture and society at www.gideonlasco.com.