Ivor Shapiro’s eloquent article (“Life, At What Price?” November) is a welcome antidote to the ideological rantings and hasty judgments that dominate media discussions of health care. It forces us to stare into the abyss that lies between what is technologically feasible and what is practical and affordable.
Like many researchers and health care policy analysts, Shapiro is preoccupied with finding an acceptable approach to rationing care and focuses on the famous Oregon experiment. Several Canadian efforts have been launched to answer the “what should be covered, and what should be excluded” question. Such initiatives are honourable in intent and often heroic in their labours. All, like the commissions established to prune services from medicare coverage in Ontario and Alberta, are doomed to failure on two fundamental and related counts: logic and justice.
The logic of in-or-out coverage decisions is that some services are useful and others are not. But in health care, services are almost never always useful or always useless. A drug that does nothing for 98 percent of people with a certain problem may be vitally helpful to a small minority. Therapies that are widely helpful may harm a few.
It is impossible to make aggregated, categorical decisions without discriminating, for or against, certain conditions and denying some people the most useful treatments. Covering services categorically is often a recipe for waste and overuse; excluding them categorically is certain to disadvantage people with legitimate needs and a reasonable chance of benefit. Fairness is the inevitable casualty of this approach.
Instead of seeking categorical wisdom, we should acknowledge that resource rationing is inevitable and develop a common understanding of limits and entitlements for making difficult, but person-specific decisions. Entitle me to a certain amount of public funding, and let my providers and me decide the best mix of services. This cannot be algebraically precise, but it is more transparent than what we do now, and it avoids the arbitrariness of in-or-out coverage. There will always be tough cases that defy every reasonable rule. But a just system should be flexible enough to deal with them humanely.
Steven Lewis
Adjunct Professor of Health Policy
University of Calgary
Missing from public policy discussions on health care, including the recent first ministers conference, are the stark issues raised in “Life, At What Price?” These are extraordinarily difficult questions that our society can no longer avoid answering. Given present health care costs—and the future trajectory is even more alarming—this single social policy area threatens to overwhelm other essential needs (education, foreign aid, infrastructure, etc.). While it is difficult to consider the value of life in utilitarian terms, your article correctly points out that if health care for the aged has become as much about postponing death as enhancing life then, clearly, it has diverged from its original purpose. Certainly, Jeremy Bentham’s “happiness-making” calculus, which considers the relative values of pleasures and pains, and Utilitarianism, by John Stuart Mill, offer important guides to this discussion. I would add to them, however, the “situational ethics” articulated by Simone de Beauvoir, Sartre, and other existential philosophers. Many of us baby boomers find ourselves in the “situation” of dealing with aging parents whose quality of life is diminishing, in some cases rapidly. It is incumbent upon us to seize this moment in time, to relive the highlights of our upbringing, and to speak frankly with our parents about the most humane approach to their dying years. Sometimes dark humour will overtake this discussion, but it can be a form of most preventative medicine. It can allow our elders to focus on the miraculous achievements of their lives and, in so doing, prepare them for a peaceful death. Living wills which clearly stipulate that no heroic medical treatments or attempts are necessary because the patient has lived a full and complete life, represent a genuine contribution to society, and one that can make the aged feel that their entire lives have been devoted to giving.
Jonathan Graham
Toronto, Ontario
Death in the Amazon
Your article on diamond mining in Brazil (“Rough Justice,” November) is a cautionary tale for the Canadian North. Like in Brazil, diamond mining in Canada began with a massive rush to stake land, much of it traditionally used by aboriginals. In one northern community, prospectors flew in and began staking the backyards of startled residents. There are now two diamond mines in operation in northern Canada, and two more have been approved. While some attempts have been made by both federal and territorial governments to ensure local people benefit from these mines, much remains to be done.
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