US Physician here. The efforts I place into keeping a patient with capacity in the hospital vary directly to the concern I have about their pathology. There is a very real subset of people who have capacity, i.e. have the mental faculties about them that I cannot legally or ethically place them under a medical hold for treatment, who clearly do not comprehend the gravity of their situation or the likelihood they will die if they leave. I have unfortunately seen a number of patients who require significant amounts of supplemental oxygen, IV medications to support their blood pressure, life-threatening infections requiring IV antibiotics, etc, who for whatever reason decide they don't want to be in the hospital anymore. Discontinuation of this life support puts their life at near-immediate risk, but the folks that are usually trying to leave in these situations are angry, distrusting of the medical system, and very goal-oriented on what they want to leave the hospital for (food because they're NPO, illicit substance use, smoking, care for their dog, etc) to the point that they're capable of saying "yeah yeah I can die whatever fucker, unhook me and let me leave." These patients deserve for me to sit down with them and try and have a conversation about what we can do to keep them in the hospital because I'm worried they physically won't make it through the hospital doors before they lose consciousness.

There are also people who have capacity, want to leave for whatever reason, and aren't literally gonna die in 5 minutes. They get papers and a pat on the back as they walk out the door.

All of this hinges on a patient's decision making capacity, and the reason every single time you want to leave the hospital against medical advice (AMA) you have to talk to one of the treating doctors is they have to determine if you have capacity at the time you're making that decision. To be allowed to leave the hospital AMA you have to be able to demonstrate that you can understand why you're in the hospital, the risks of leaving the hospital AMA, and hold consistent and logical (not necessarily rational) positions on decisions/priorities. If you can't do any one of those things, you by definition don't have medical decision making capacity, and I am not only legally allowed to, but I'm ethically obligated to keep you in the hospital to be treated until either a surrogate decision maker with capacity can be identified OR you have return of your capacity after your illness improves and we have this conversation again.

From an EM perspective, patients are often stupid as fuck and wouldn't know what was good for them if you beat them over the head with it. Sometimes their stupidity brings acute death if they leave my ward, and I don't want that on my conscience, not to mention legal exposure. If I thought a patient was wanting to leave for some stupid reason and life and limb is on the line I would absolutely do everything short of directly lying to a patient to keep them under care until they are stabilized. Full stop. It is my ethical and legal obligation to treat patients, even if they are too ignorant or obtuse to understand that is the reason any of us are there. Call it mind games, manipulation, whatever; I do not want a sick patient leaving until I am sure that they won't die from what they came to me with or be back within 24h for the same thing, and I will do whatever I can to keep a patient's stupid ideas from getting them killed.

I guess you could also ask what’s the reason for working at a suicide hotline? Seems similar enough in many cases.

Alternatively, I’m sure many patients simply see attempts to keep them there as upselling. They feel fine, etc. It’s not the medical professional’s fault our healthcare billing/payment system sucks. Many genuinely care, and without some level of urging.. how would a patient know an issue was urgent?

I assume most people in healthcare do the job because they actually do care.

The insurance companies create an environment that makes it feel like it's providers-vs-patients. The ruling class has been doing this kind of manipulative crap to working people for generations.

I think thus just boils down to whether you think Kantian or Utilitarian ethics is more correct.

I think it's not just ok, but morally obligatory to do your best to promote people's well being, even via manipulation, regardless of if they are hellbent on fucking themselves over. Human beings are deeply, deeply imperfect, and we do not always make good rational decisions. With respect to medical care specifically, if someone refuses something that is objectively a clear benefit regardless of potential unknown context, then they are not doing so rationally, and there's no good reason to just throw your hands up and give up on them for that.

Wouldn’t it be better to hand the drunk suicidal person a gun and move on?

What is the premise? Most countries, US included, does not grant doctors, nurses or any medical professionals or staff the power to hold people against their will.

say you force a cognizant patient to stay at your unit

This is not remotely allowed

besides the whole oath thing there are provisions in the aca the punishes hospitals if people are back in the emergency room within a certain period of time.

I think you generally shouldn't make it super easy for people to harm themselves. They should be able to do so. But I believe it should require a mininum amount of effort.

Also you might be invested a bit. If you did 6h of surgery on them. Or wiped off their butt for a week, I suppose it might hurt to see that's been in vain, or at least made worse. I'm not a doctor or nurse and only worked briefly in healthcare. But I suppose it's the same as with other professions. I'm also offended if I put in quite some effort to get something right, strive for a perfect result. And then someone slaps on a badly-made and buggy UI... That's just taking pride in your work.

Plus with hospitals, there is liability, the hippocratic oath. And you probably learned that job because you're intrinsically motivated to help people. Not because you're interested in philosophy and freedom. And then trying to help will be more natural to you.

Plus, hospital staff is desensitized to a degree. They deal with a lot of people who are not sound. Mentally ill, are making a lot of bad decisions and that ended them up there, took drugs and are doing weird things, or the drugs they're getting as medication affects them. Nurses might just be desensitized by their everyday job once they face the one person that's talking about the same weird things, just for a sound reason. Because what you tend to see all day, every day is people trying to rip out the tubes directly attached to their arteries, wanting to smoke in urgent care, while being attached to the oxygen tank directly next to them. Every other week someone will try to just walk out with big open wounds... And you can't really have them blow up the hospital, or die at the bus stop infront of the hospital, regularly. It's just difficult to balance all of that.

I'm not in healthcare either and I totally see your point.

But, i guess, the situation is complicated. What do you do with a 7 year old child who doesn't want to go to school? Send them anyways, probably, tell them they have to because it's good for them. Now, why do parents behave that way? Because they assume the child doesn't understand the full implications of their choices.

With patients it's a bit similar. Sure you can tell them they're going to die if they refuse medication, but will they really understand the depthness of that? Probably they can't even imagine it, idk. Could you imagine your own death? I guess for a lot of people that's just a difficult thing to imagine, possibly also because monkey brain conveniently completely has a blind spot for that option (remember people driving recklessly, for an example).

So, you have to estimate: Does the person really fully understand what's happening, or are they just brushing it off as an "yes the doctor wants to scare me to give more expensive treatment, extracting money out of me" thingy. You can't assume all patients have studied medicine and understand the deep connections. Does the person really know what they're talking about, or are they only looking at things at a superficial level?

It's entirely unprofitable to send a bill to a dead patient

My friend in recovery had relapsed and fell off a bridge. The doctor hated him. Told him that he couldn't leave the hospital because his creatinine was dangerously high. I helped him get out of there.