Public and Private Health Care, Freedom and Responsibility

When the Premier of Newfoundland, Danny Williams, opted to go to the US (Miami) for his heart surgery earlier this month he ignited a flurry of discussion about public and private health care and what should, and should not be available in Canada. All of the details are not available, but the main gist of the story is that Premier Danny Williams needed heart valve surgery that was not available in Newfoundland. He then opted to pay to have the surgery performed at a medical centre in Miami. He has subsequently claimed that the minimally invasive surgery was not available in Canada, a claim that has been strenuously denied by cardiologists across the country. “It’s my health, it’s my choice,” he is quoted as saying.

In many ways the exact details of the case are not the critical issue. What this situation serves to do – in a very high profile fashion, is highlight some of the debate about what should – and should not be available and what limitations on personal freedom should be permitted in a free and democratic society. Danny Williams was free to take his cheque book and buy his care in the US. After all it is indeed his health and his choice; however Danny Williams could not take his cheque book and buy his care in his own country. Canada is one of the very few countries in the world where there is no private health care. It is easy to see how this is a limitation on individual freedom. A Canadian is not permitted to take his or her own money and purchase a wide range of medical services in his or her own country. Conversely a Canadian medical practitioner is not allowed to set up shop and provide that same wide range of medical services. What is the public good that could justify these restrictions on individual freedom?

There are a variety of arguments in favour of the prohibition on private care, some of those arguments are practical – others are ideological. Let’s have a look at them. The principal practical argument against permitting private care is that somehow the existence of private care (a two-tiered system) would undermine or diminish the publicly funded system. This argument gets vigorously pursued in both directions. Thos who think that private care would undermine the public system argue that private care would siphon resources, facilities, talent, staff etc away from the public system. They also argue that those with the resources to afford private care (or private insurance for that private care) would then become demotivated to protect the public system. And, as those with the resources to afford private care or insurance, are those with the preponderance of political power, the public system would decline through lack of funding and political neglect. On the other side, however, proponents of private care argue that the influx of additional funds into health care as a whole cannot help but be a benefit. They argue that increased resources would increase facilities and personnel, and that the for-profit facilities would take people out of public health care waiting lists and so would result in better care for the entire community. It is difficult to know what evidence would settle this one way or the other. European countries mostly have a mix of public and private care and many observers agree that the French health system is amongst the world’s best, most comprehensive and affordable.

But there are ideological arguments too. Some would argue that permitting people to pay for health care embodies a fundamental inequality. They argue that each human life is inherently of the same value. However, if we allow people preferential, paid access to health care services, if we allow them to buy their way past queues, or to buy better treatment, even if those waiting in the queues are no worse off (in fact, on ideological grounds, even if they were better off) then we have created an inequality, we have manufactured an injustice, we have valued some people more than others – and we Canadians, don’t do that. But, of course, there is ideology on the other side too. As we noted earlier, preventing people from buying products or services from willing sellers is a restriction of personal freedom, which, those on this side of the argument would claim, is unwarranted by any public good that might accrue from the restriction. What do you think?

Finally, the debate about public and private and public health care leaves untouched the very wealthy, like Danny Williams, who can just take their cheque books and buy the services they want where they want. But Danny Williams isn’t just another rich guy; he’s the Premier of a Province in a country where the provinces have jurisdi ction over health care. I’ll leave it up to the reader to decide if special considerations should apply to political leaders... What do you think?

A final word on pushing and shoving

The topic of secondary triage criteria and their applicability in a pandemic has aroused a great deal of debate in many different venues. At the Queensway-Carleton Hospital (QCH)in Ottawa we decided to try to take a formal look at the issue. We arranged a debate -- in standard debate format, on the resolution: "Be it resolved that the QCH adopt societal criteria for the allocation of scarce medical resources in the event of a catastrophic pandemic”. The resolution was deliberately vague on what those "societal" criteria might be in order to generate as open a discussion as possible. The debate was impassioned, and the questions from the audience interested and interesting -- but it is the result of the voting that is most noteworthy. The votes split 21 to 19 against the resolution, which I would say, is about as close to a tie as you can get. Our approach was unscientific, and of course the results were swayed by the approaches of the debaters,but that close a result, I think, means two things. First, we are split on this topic. There is not agreement that we unequivocably should -- or should not introduce non-medical, or "societal" criteria into triage decision-making. And second -- if we don't have a clear agreement to change what we currently do -- we should be cautious about taking a path that leads away from our currently espoused and practiced values.