There is something wrong with medicine in Canada today. This conclusion can and probably has been reached by any member of the profession who has paused from his or her daily endeavors to consider the current state of medicine in this country. Despite rather remarkable advances in the art and science of medicine patient care is deteriorating. The availability of medical services is diminishing and waiting lists are growing longer. Patients are often obliged to seek medical care in facilities far from home. The cost of health care in Canada has been spiralling upwards out of control, and predictions for the future portend the collapse of what was once an excellent health care system.
Caught in the middle of the unfolding disaster is the Canadian physician. On one side the profession finds itself beset by abusive governments that seek to offset the collapse by controlling the physician and the way he practices his profession.
On the other side is the public who, for the past quarter century has been told by the organizers of socialized medicine that health care is now "free," and that all they need do is to profess a need for any service and it will be provided. With the consequent open ended demand being placed on finite resources it was only a matter of time before the situation deteriorated to its current state.
Many people seem to realize that something isn't quite right, and as is characteristic of our culture, people are looking for someone to blame. The politicians, aided by what is almost exclusively a socialist press corps, have very skillfully been able to portray the doctor as the cause of the crisis, and themselves as the saviors of the system. The public, sensing that something is amiss, is looking for its own answers, and has also labeled the medical profession as being primarily to blame.
Amidst the maelstrom walks the physician, confused, angry, demoralized and apparently incapable of changing the situation. He has worked excruciatingly hard to acquire the knowledge and skills he now possesses. Yet he is subject to lies and equivocations about his level of remuneration. Despite intense dissatisfaction with the current state of affairs, he continues to work and care for his patients. Yet he is vilified by the government, the public and the press as being the agent of destruction of health care in Canada. Why?
Did not the profession agree to be part of socialized medicine? Did it not help the government set up the system, and has it not continued to work with the government through "meaningful dialogue" to keep the system going? Do not Canadians, despite the current problems continue to receive excellent care, to the extent that our system is often looked upon as a model for other countries? Regardless, the physician today finds himself with few friends in the Canadian social/political scene. Why?
How is it that what was once considered a model of medical care for the world can be on the verge of collapse? How is it that the doctor, once revered is now reviled? Why?
The answers to these questions are not self evident. However, it is clear that something is very wrong, which implies that at some point the profession, and perhaps society as a whole, committed a fundamental error in structuring the delivery of medical care the way it has. Somewhere, either in its view of itself and its function, or its relationship with patients and the government the profession has made an error of overwhelming magnitude that has precipitated the current crisis. Conceivably, it could be the government and the sundry other socialists who infest the corridors of power in Canada who have erred, but as I will illustrate, there is no error on their part.
This essay will look at the nature of the error, which will be shown to be the acceptance, by both the physician and society as a whole, but most importantly the former, of the validity of the basic premise that construes medical care to be a right. The essay will discuss the origins of this error, its ramifications on the practice of medicine in Canada, and how it has lead to the current debacle. Solutions to the current crisis will be considered.
Government Intervention --- Health Care as a Right
A brief look at how we came to be in our present state is in order. Prior to the advent of socialized medicine, medical services were considered to be part of the market place. Goods and services related to medicine were paid for by those who consumed them, i.e. the patient. There were various insurance programs available, but the basic principle was that if you wanted medical care, you paid for it. This was perceived by the socialists as being unfair, as some members of society could not afford the cost of some medical services. Medical care was seen as being available only to the privileged few who could afford it. The solution to this supposed problem was to have the responsibility for the payment for medical goods and services assumed by the government. This way nobody would be denied access to medical care for lack of personal resources. The rationale behind this was that medical care should be looked upon as a right to which everyone should have access.
While there may have been some uncertainty on the part of the medical profession as to exactly what was occurring with this change, the socialists knew exactly what they were doing. Monique Bégin, who, as federal Minister of Health, was one of the chief architects of the current system wrote, "Practically overnight, health care changed from a privilege to a right."(1)
Notwithstanding the fact that the characterization of health care as a privilege was a gross misrepresentation of its true nature, the consideration of health care to be a right represented a profound shift in how our society looked upon health care. Up until that moment, each of us was considered to be responsible for his own medical requirements. We were not able to force others to pay for goods or services that we required, either directly or indirectly via the government. With this change however, each of us could lay claim to whatever medical goods and services we thought we needed and they would be provided, regardless of our own ability to pay for them. This effectively removed medicine from the market place.
What does it mean when we say that something is a right? Mankind has grappled with this question for centuries. To date most of the suggested answers have been incorrect and have lead to much human misery.
A succinct definition was provided by Ayn Rand (1905-1982) when she referred to a right as a "moral principle defining and sanctioning a man's freedom of action in a social context."(2)
A right sanctions an individual's ability to act to further his or her own life, without being subject to, or subjecting other people to, compulsion. This sanction applies to each and everyone of us equally as individuals.
Much confusion has stemmed from the misinterpretation of this concept to mean that an individual may do whatever he pleases. If one remembers that this idea applies to each of us, and that we may not violate another's rights, the error of this interpretation becomes clear.
Note the importance of the word action. A right is the freedom to act or to work to acquire something we desire, it is not the right to something. The failure to appreciate the latter point is of paramount importance in understanding our current problem.
Often today a right is considered to be a positive. That is to say a right is considered to be an entitlement to some good or service. This could be virtually anything, such as housing, unemployment insurance, a minimum wage or medical services. Correctly interpreted, a right is a negative, protecting an individual from or against coercion by his fellow man.
Why is this the correct interpretation of the concept? It stems from the fact that the goods and services often posited as rights are produced by other people. It should be clear that houses, for instance, do not exist in nature but are produced by someone. If we consider houses to be a right, then clearly someone is going to lose out. Someone will be producing, while others, laying claim to their rights, will be consuming their product.
An often heard countering argument at this point is that we would get the government to provide these rights. This argument fails when one realizes that governments do not create wealth. A country's wealth, i.e., its goods and services, is always created by its people. Governments acquire wealth by taking it from the people in the form of taxes. Thus suggesting that a government can provide these rights does not change the fact that someone will be compelled to produce while others consume his or her product. Hence, if one accepts the notion of positive rights, then somebody's rights must be violated to secure these rights, and as Rand suggested, "any alleged right of one man, which necessitates the violation of the rights of another, is not and cannot be a right."(3)
Given the above, what then are actual rights, and how do we apply the ideas to medicine? Reduced to fundamentals, rights consist of "life, liberty and the pursuit of happiness." This means one may act to sustain one's life, that one is to be free from the use of force by other men, and that one may act to secure one's own happiness. (Note the choice of words: the pursuit of happiness. One cannot sit on one's hands and demand that others make one happy, but one may take whatever actions one chooses to make one happy, while respecting the right of others to do the same.)
Note that none of these items is someone else's product. They are accorded to each human being as a birthright, by virtue of the requirements of our nature as rational beings.
An often heard argument suggests that since one has the right to "life, liberty and the pursuit of happiness," then medical care must be a right. For if one is seriously ill, one's very life is threatened. And if one has a right to life then one has a right to those medical services necessary to sustain one's life.
However this analysis neglects one side of the equation: the doctor or other provider of medical services. The doctor too has an equal claim to his or her life, and the products thereof.
In addition, one cannot dispute the fact that we are a mortal species. At some point we all die. No amount of government largess will ever change that fact. Thus the question arises, do we have the right to stay in the land of the living longer at the expense of our fellow humans? Given the fact that when contemplating our mortality we are a timorous species, many would likely answer with a loud, yes!
Remember however that one individual may not violate another individual's right to their own life in the furtherance of his own. The philosopher Leonard Peikoff crystallized this idea nicely when he wrote, "The moral principle here is clear-cut: a man has the right to act to sustain his life, but no right to loot others in the process."(4)
Having indicated why health care is not a right, we must now answer the question, what then is it? The answer to this question has been alluded to earlier.
Is it accurate to say that health care is a privilege granted to the few who can afford it? Clearly no, for the following reason. It is obvious that the goods and services that are known as health care do not exist in nature. That is to say, they do not exist in the wild as do fish or trees. The raw materials are there but the items themselves are not. One can not walk into a forest and pick a CAT scanner off of a tree. How then do these items come into existence?
Put in its simplest terms, they are produced. This means that their constituent raw materials are acted upon by the minds and efforts of human beings who fashion the raw materials to suit their needs. Indeed, the reshaping of nature to suit its needs is one of the main characteristics of our species.
Having come to the obvious conclusion centuries ago that medicine is beneficial, humanity has been altering the environment ever since, which in the context of medicine has resulted in the current production of the goods and services known as health care.
Clearly therefore, health care is a product, as much as a loaf of bread or a pair of shoes are products. Thus the characterization of medical care as a privilege bestowed upon the few who can afford it is a brazen misrepresentation of its true nature. It cannot be granted to anyone by anyone.
Issues surrounding the concept of rights can be quite complex. However there is a very simple rule of thumb one can use. Ask if the good or service being touted as somebody's right is the product of someone else's life. If so, it is nobody's right, other than the person who created it.
If one concedes that medical care is indeed a right, what are the unavoidable consequences of that concession? There are many, both short and long term.
In the short term, it may appear that society had taken a great step forward. With the influx of 'government money' into the system, there was an explosion of growth in the field. Everyone who needed medical care could obtain it. New hospitals were built, new programs were established. Everyone who wanted a doctor could get one and the number of doctors rose dramatically to meet the demand. The medical profession, instead of having 20 to 30 percent unpaid bills, now received payment for all their patients. Physician's incomes rose rather nicely in the early years of medicare. Yes doctor, the hook was sweetly baited.
But what about the long term consequences? These were certainly less obvious at the beginning of socialized medicine, but even a cursory glance at socialism's record should have told us what to expect.
In the next issue of the Medical Sentinel, we will conclude with Part II of this article.
1. Bégin M. Medicare --- Canada's Right to Health, Montreal, 1988.
2. Rand A. Man's Rights. The Virtue of Selfishness, New York, 1964.
4. Peikoff L. Medicine: The Death of a Profession. The Objectivist Forum, New York, 1985.
Dr. Aubrey is an internist and rheumatologist in Newmarket, Ontario, Canada. His e-mail is firstname.lastname@example.org.
Originally published in the Medical Sentinel 2001;6(1):26-28. Copyright ©2001 Association of American Physicians and Surgeons.