What's Wrong with Healthcare?

Thinking inside and outside of the healthcare box. After 41 years of family practice, what's happened to Canada's healthcare system?

Sunday, January 15, 2006

Are Friends of "Medicare" Friends of Canadians?

Ethicists have stated that in family medicine, we have an ethical obligation to assist families to grow in their ability to make choices and take responsibility for those choices with regards to their health. If this is true, is it not also true that our medical leaders and government leaders should work together to help Canadians make good choices regarding our health care system? Ethical transplant surgeons have difficult choices to make with respect to the patient that would benefit most from an organ transplant when there are a limited number of organs available. This would be called an absolute lack of a resource. But what if the restrictions to transplantation were budgetary? What if the transplantation program was only allotted so much funding and “cost” determined how many surgeries could be performed. What if the number of Intensive Care Beds in the Calgary Region was determined by competitive medical funding interests within the region and the “upstream driver” of that---competitive funding interests of the provincial government---- and the upstream of that, competitive interests of the federal government and society as a whole? Should the medical profession, from an ethical perspective, become embroiled in a “relative” resource allocation system? Some physicians obviously felt we had an obligation to society as a whole, and that, to them, meant working with a cost driven system to best use the resources allocated to health care. I say our obligation to society is best served by remaining the patient’s advocate, and, working within that society to help patients and families to grow in their abilities to make choices and take responsibilities for their choices! This would entail at the provincial and federal level, advocating for resources but also advocating for alternate provider systems. The profession has failed miserably in this regard!
Before ‘Universal Medicare” in Canada, doctors determined that surgical units always needed a 10% vacancy, Medical Units a greater percent vacancy, and Pediatric Units even a greater percent vacancy. This was determined on the probability of medical events occurring that would require appropriate acute care (hospital) beds. The present situation is that most acute care facilities run at near 100% capacity most of the time!
This means that to a large extent physicians are making decisions based not on absolute scarcity but relative scarcity. We base most things on a risk basis; emergent, urgent, semi-urgent, and elective. Family physicians are encouraged at all levels (teaching universities, continuing medical education, regional administration, etc.) to think in a cost effective manor and to prioritize both medically (risk) and from a cost perspective. Emergency physicians must stratify the patients so those at highest risk can be admitted to scarce medical beds. Intensive care physicians often determine which patient, of a multi-car crash, most critically requires the last I.C.U. bed.
An argument could be made that this is their job (they are the best trained to make those decisions) IF the funding available, as in the case of organ donors, was an absolute, but it is not! Government funding to health care is relative and determined along with many other priorities including, but not limited to, infrastructure, tax cuts, education, and many other social programs. Why then has the medical profession bought into this monopoly? To some extent I think this was a case of the governments saying: “We are going to do it with or without you and you know we are going to screw up”.
Canadian courts certainly have for years told physicians that their primary responsibility is to the patient. The excuse of “lack of resources” has not stood up in a Canadian Court of Law as a defense for a medical practitioner. We have been told by judges that patients who are waiting on “lists” are at risk and should be told that there are private services available to them in Canada and the U.S. More recently the Supreme Court has stated that the Quebec Government must provide options for its citizens when waiting lists impact their right of self health determination. Calabresi and Bobbit in “Tragic Choices” stated in 1978: “Scarcity is not the result of any absolute lack of a resource but rather of the decision by society that it is not prepared to forego other goods and benefits in a number sufficient to remove the scarcity”. It should be noted that this scarcity has only become more acute with time. Society must ask the question, as its members stand in long medical lines, if it wishes to continue allocating tax resources in this manner. The Medical Profession must ask its-self if ethically it can continue to condone being advocates for a monopolistic system that continues to allocate health care as an ever increasing scarce resource, or return to the premise that we are advocates for the patient above all other ideologies.

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