Medical Rationing in Canada
Such risk has thankfully disappeared from the shipping industry, as well as other sectors. The airline industry, for example, is famous for a culture of safety regardless of passenger class, age, or ability. Can we say the same about medicine?
In the USA, the College of Physicians has recently called for more “parsimonious” care 2, in part to save valuable resources. Though some efforts (such as the recent Choosing Wisely campaign) to avert wasteful or futile care are clearly necessary, language promoting potentially skeletal care undermines a culture centred on equity and safety. How do we resolve this potentially dangerous paradox?
Koch reminds us that to deny a patient with acute polio an iron lung was once inconceivable. Yet today, we consider it natural to not put all patients with renal failure, or even the majority of such patients, on dialysis. Rather, we debate on the values that should guide who gets treated, and who gets left out. But increasingly, more and more are left out. Has the lifeboat ethic extended into medicine?
In practice, each province individually determines its insured basket of services. The resulting level of 'comprehensiveness' is revealing for its uniformities however: we are told that accelerating budgetary and demographic pressures must lead to more scarcity. We are led to believe that less and less medically useful services can be covered, including essential services such as physiotherapy. But it is less than clear how these choices are made.
Certainly, the trend in medicine has followed the trend in wider society: an over-valuation of expensive, technological solutions at the expense of more traditional, human-scale ones.
We must ask ourselves whether rationing has become too central a focus in our health care system. Could it be that we are debating how, precisely, to prioritize issues in a hemorrhaging system, without agreeing what is causing the hemorrhage? Could it be that we no longer question the underlying assumptions that led to increasing rationing in the first place?
References:
1. Koch T. Thieves of Virtue: When Bioethics Stole Medicine. Mit Press; 2012.
2. Snyder L, for the American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: Sixth Edition. Ann Intern Med. 2012;73-104.
Photo Credit: Couvrette/Ottawa