Obama did it. Trump does it. Trudeau does it too. Politicians talk about values as if they know what voters think.
A politician promotes his values to normalize his vision.
Tricky politicians use familiar words and give them new meaning. They use popular support for one thing to build support for something completely different.
For example, since everyone supports motherhood, it shows we support apple pie too.
On his quest for state medicine, Tommy Douglas told a story. Young Tom needed surgery. His family was poor. A surgeon fixed Tommy for free. It was great for Tommy, but what about all the other sick kids? Is it fair that farmers must choose between losing the farm and losing a daughter’s limb?
Compassion Not Equality
Most Medicare books start the same way. The author tells a story about disease and financial ruin, before Medicare. They appeal to compassion and inflame fear of loss. People should never suffer without care or go broke from medical bills.
Canadians agree. We are moved by suffering and loss. And that is where we get tricked. Douglas and company trades compassion for “equality” and fear for “care regardless of ability to pay.”
But compassion is not the same as equality. They are as different as colour and temperature. No one knows the temperature of purple. They are different categories. Compassion and equality are different categories also. It is a category mistake to conflate the two.
Compassion is a human emotion. Equality is a state of affairs: an ideal almost impossible to measure or describe, and rarely achieved.
Medicine stems from the desire to alleviate suffering. Medicine grows from compassion, not equality or fairness. Doctors and nurses employ extravagant excess to help the sick. Doctors do everything to save a life. Compassion drives doctors to excess.
The first supporters of Medicare supported it because they supported helping patients. They also feared losing their farms if family fell sick. Compassion is not the same as equality or fairness. We expect to invest exorbitant time, money, and effort into our sickest citizens. This is the opposite of equality.
Is it Fair?
As patients, we hope the system will be fair when we get sick, but the system does not operate on fairness. Fairness is not its driving principle.
An egoist might insist that Medicare functions only because each individual believes she will get care when sick; compassion means nothing.
Regardless, Douglas did not campaign on fairness and equality. He campaigned on compassion. Out of compassion we pour most of our healthcare dollars into a few very sick people. There is nothing equitable about it.
Of course, we hope for the same care when we get sick. But to transform a compassionate motivation into something that appeals to voters’ selfishness is twisted and wrong. Canadians supported insurance out of compassion, not equality.
Janice Stein writes that, “…Universal care is part of a society that values fairness…” It is the Canadian creed. We believe that fair societies have universal care, and universal care makes societies fair. Canada has universal care, so Canada is a fair society. We value fairness. Valuing fairness is the same as valuing equality. We dislike extremes. We like average.
But is this correct?
Big, talented hockey players beat small, unskilled players. And Canadians love it. Furthermore, Canadians try to get ahead. We work to improve our lives. Being better off means our life is better: better than our peers’ who did not try to improve their lives.
Of course, some people cannot improve. They need help. Others can only improve a little. They need help too. That requires compassion, not equality.
Tommy Douglas did not campaign for care regardless of ability to pay. He campaigned on compassion. He said no one should have to choose between losing his farm and losing his leg because he could not afford care. Argument for equality came later.
People wanted to be free of the fear of catastrophic medical costs. They wanted insurance against loss. They feared getting sick and not being able to pay for it. This is not the same as saying that Medicare is built on the notion of care regardless of ability to pay.
Compassion and Fear
Douglas appealed to compassion and fear. Most people want to help those in need. And no one wants to lose the farm. We all feel compassion and fear.
These are good reasons to support some kind of insurance scheme. It need not be state funded. It need not be state run, regulated, and micro-managed. But most people support some way to help everyone in need and to protect against loss.
Politicians and Medicare authors are right. Values normalize a vision. Let’s focus on real Canadian values and not be tricked by a false vision.
It’s a good piece as always, Shawn, but I’ll argue it misses the problem we have around the discussion of our current Medicare mess.
The problem isn’t what Tommy Douglas’ vision or proffered values were at the creation of Medicare. The problem is that we pay any attention to his thoughts at all.
Tommy Douglas is one thing more than anything else, and that is dead. We are now decades removed from his creation of Medicare, which was designed to solve a particular set of public policy problems at a particular time. By all means admire the man’s passion, achievements, and sentiments.
Call him the greatest Canadian (to the chagrin of our national Pope, Don Cherry). But it’s absurd to take a 1950s policy and assume it will remain valid and useful for all time.
We change with the times in our approaches to foreign policy, consumer safety, justice, technology, and civil rights. But on this one thing – legally enforced single payer rationing – any deviation from our current sorry state is tantamount to a betrayal of our national identity. It’s as ridiculous as the zeal we see in America over gun rights. At what point do people admit maybe these laws have outlived their usefulness?
Medicare is an insurance plan, the Canada Health Act a law governing interjurisdictional transfers. Bureaucratic constructs, words on a page. It would behoove everyone – doctors, nurses, patients, taxpayers – to stop fighting over a fictitious national identity, and debate a health care financing scheme that’s equitable and valid for the times we live in.
The Canada Health Act became law in 1984 and has not been amended to any significant extent since then. 35 years! The Ontario Health Insurance Act became law in 1972 and has not been amended to any significant extent since then. 47 years! Just like apple pie and motherhood.
Excellent points, Perry.
The federal government has tried to insert itself into healthcare with its ‘spending power’ for the last 60-70 years, without going through the more difficult process of a constitutional amendment. Instead, it has funded hospitals (1948), funded 50% of the cost of hospital care and diagnostic services (HIDSA 1957), funded 50% of medical care (MCA 1966), then cancelled the 50% funding promises and switched to block grants (EPFA 1977), and then finally held the provinces hostage by paying cash for provinces that play along with the Canada Health Act (1984).
The reason we have federalism is to reduce the harm one government could do if it controlled healthcare for the whole country. It is a harm reduction approach. All the other reasons are important, too — localism, distributionism, etc — but the main reason we should not have the federal government running the whole show is to prevent pain and suffering for the whole country when they make a bad decision. At least when a province does something stupid, it only impacts part of the country and everyone else learns from it.
Thanks for drawing attention to this!
Well said, Frank!
I have nothing to add to your excellent comments. I hope everyone takes time to think through what you said.
#ThisMayHurtABit
Another great, insightful article, Shawn.
Want to learn more about Tommy Douglas and the Saskatchewan Experiment?
Pre-order a copy of my forthcoming book, This May Hurt A Bit: Reinventing Canada’s Health Care System.
Solve the real problem, not just the political problem.
https://www.amazon.com/This-May-Hurt-Bit-Reinventing/dp/1459742435/ref=sr_1_1?s=books&ie=UTF8&qid=1546785320&sr=1-1&keywords=this+may+hurt+a+bit … … … … … …
Thanks Stephen! I’m sure everyone will enjoy your book, also!
Stimulation piece. I also suggest reading “All Together Healthy” by Andrew MacLeod (2018) to add to the conversation of fairness, compassion, empathy and equity (which is preferred word in my opinion). Our society doesn’t really practice these values. By focusing on the universality of CARE in our health CARE system, we numb the mostly uniformed public away from what the real societal needs for HEALTH and WELL-BEING are.
Thanks Johny
You packed a tonne of opportunities for discussion into a very short comment. Indeed we could write a whole post on just the notion of equity. I understand your comments about HEALTH and CARE. They align well with modern sentiment.
I guess I am old-fashioned and believe that medicine grew out of a desire to help sick people. That is not to say that helping healthy people stay healthy is unimportant. Of course we should try to keep healthy people healthy. I am not sure that is the reason medicine exists.
Medicine should cure sometimes, comfort often, and care always. Trying to make medicine into prevention, promotion, counselling, support, and every other thing related to human physiology dilutes medicine from caring for people in need. I realize that this paints me as a heretic and hopelessly out of date. I just think that if medicine tries to be everything it will be nothing.
Thanks so much for taking time to read and share a comment!
It is not old-fashioned to state that medicine is about caring, empathy and curing, I agree with you and believe to have never written anything to the contrary. However, in the day and age where everything is connected with everything, medicine can no longer stay within its own boundaries which have become semi-permeable. In that context, I also agree with you that it is out-of-date to state, “Trying to make medicine into prevention, promotion, counseling, support, and every other thing related to human physiology dilutes medicine from caring for people in need.” Caring for people in need means more than medicine and more than curing. The 2013 CMA report “What makes us sick?” stated that physicians have to advocate for population health, and there are many national and international examples of how that was and is being done well. I submit Semmelweiss as an example of a physician who didn’t stick with disease, he went down to the origin of the disease and ‘descended’ into prevention and changed the environment, preventing thousands of deaths that were up to then considered normal part of medicine. Cure and care can and need to go hand-in-hand for so many reasons, and physicians are the ones who understand disease from its origin (care for population health) to the end (care for individual disease cure). Dr. Marmot’s book, “The Health Gap” is an outstanding resource on the topic. As always, a stimulating dialogue makes us think and reflect for the betterment of humanity, and for that I am grateful.
Great comments, Johny! Well said.
I use ‘cure’ and ‘care’ as they relate to curing or caring for individual patients. That is the heart of medicine.
Caring for populations is great too! Dr. Snow saved many more lives by removing the Broad Street pump handle and single-handedly stopping the Cholera epidemic in London 1854. But this is the ambit of public health. Public health and medicine overlap but they are each unique and in a category all their own. It harms public health to turn it into medicine. It harms medicine to turn it into applied public health. We should use the tremendous and wonderful tools and approaches of public health thinking. Public health can inform us at the bedside. But to say that the whole of public health belongs inside medicine, or that the whole of medicine belongs inside public health, does a disservice to both fields of inquiry.
Fields of study overlap all the time. We might consider anthropology and history, or architecture and engineering. Each field is distinct and useful because it is distinct.
No doubt, everyone benefits from doctors adopting a broader, population-based mindset. But I do not think we advance by trying to turn clinical medicine into population health.
Thanks again for a stimulating conversation! Excellent.
Cheers
There was a long contextual history to the introduction of publicly-funded and publicly-administered medical care insurance in Saskatchewan in 1962. During the Great Depression in the 1930’s everyone in Saskatchewan was suffering, including many physicians, because their patients could not afford the fees for medical care. Many physicians welcomed the introduction of the Municipal Doctor Program through which municipalities funded medical services through municipal taxation. Over the ensuing decades leading up to 1962 , the Saskatchewan government introduced publicly funded care for all patients diagnosed with tuberculosis and cancer. Eventually all hospital services were also publicly insured. These public policy decisions were widely supported by the citizens of Saskatchewan. Most citizens perceived the expansion of this policy to cover physician fees as a rational extension of strategies that had wide public support over three decades.
The medical profession tried to mobilize public opposition to Mr. Douglas’ plan to publicly insure physician fees but it became clear that the majority of citizens favored the policy. I don’t think it is accurate to claim that Mr. Douglas did not campaign on a platform that access to care for all should be independent of ability to pay for that care. That was at the very heart of his campaign and that position received broad public support.
Thanks so much for your comments, Dr. Kendel.
I am glad that you drew attention to the history around Medicare. I would encourage those interested to dig into Dr. Doig’s “Setting the Record Straight: A doctor’s memoir of the 1962 Medicare crisis.” Dr. Doig offers a thorough, detailed, and heavily referenced history of the 1962 doctors’ strike. Dr. Doig was at many of the tables that others reported on secondhand and after the fact. He describes each event then reviews the range of media articles written about the event and shows how they align (or not) with official government documents and letters. It probably won’t surprise most of us that the Toronto Star hated doctors just as much in 1962 as it does today. The popular revisionist history of greedy doctors punishing patients couldn’t be further from the truth. The public supported their physicians in the fight for freedom from nationalization of a once noble profession.
Douglas appealed to Saskatchewan farmers’ sense of compassion and their fear of losing their farms. Full stop. He did not campaign on the partisan political ideologies that parties attached to Medicare to further their own ideological dreams.
I suggest that the sooner we return to compassion and re-visit whether Medicare does a good job of dispelling fear of loss the sooner our beloved system will start to function as it should.
Again, thanks so much for taking the time to read and share a thoughtful comment!
Best regards,
Shawn
By the title for his book, Dr. Doig clearly disclosed that he wrote from the perspective of a physician. There is a wide range of perspectives on the history leading up to the introduction of “Medicare” and the tumultuous events of 1962. Because the College of Physicians & Surgeons of Saskatchewan was also functioning as the Sask division of the CMA at that time, the College represented the interests of physicians in their interface with government. The College amassed a huge inventory of archival material related to these events.
Dr. Doig was afforded access to this archival material in the course of writing his book. I also had access to all of this archival material over the course of my 25 years of service as the College Registrar. Because I have an interest in Saskatchewan’s history, I devoured this information over the course of those 25 years. While I respect Dr. Doig’s interpretation of this archival material, there is no doubt that other interpretations can be reasonably drawn from the same material.
I was not a physician in 1962, so I experienced the events of that era as a citizen rather than as a physician.
Ah yes, the genetic fallacy. Anything written “from the perspective of a physician” must be inaccurate, because, well, he’s a doctor!
We should examine the facts that Dr. Doig reveals and debate whether he has interpreted them well. We cannot dismiss his data or arguments without first examining them. Furthermore, to dismiss someone’s first hand accounts as simply “the perspective of a physician” seems to miss a great opportunity and verge on willful blindness.
I do not buy into the postmodern belief that all truth is relative. Most doctors do not either. Doctors believe that it makes a difference if you give 0.25 mg of Digoxin versus 0.025 mg. Historical facts, like drug dosages, cannot be dismissed because they were reported by a doctor or a nurse, a journalist or even a 10 year old.
Based on your 25 years of devouring the archival information, I suspect that you might enjoy reading Dr. Doig’s book.
Thanks again for offering a thoughtful comment!
Cheers
I have read Dr. Doig’s book. I knew him personally. Throughout the many years I knew Dr. Doig (he is now deceased) I held him in high esteem. I respect the perspective he presented in his book. The reality is that people have a range of different perspectives on how Tommy Douglas presented policy options to the public in 1962 and how the public responded.
Excellent! I agree, there are a range of perspectives, for sure. It would help if we pulled them out more often.
Cheers
First time I have heard of the Genetic Fallacy. I have always considered those types of arguments as variations of Ad Hominem. You motivated me to read a discussion online by some philiosophy students studying logic. Lots of nuance there but it now seems to me that Ad Hominem is a subtype of Genetic Fallacy. It’s always nice to learn something new. Thanks Shawn
Glad you liked it! I find it useful when people try to dismiss an idea because it came from a source they do not like. If a child tells you the house is on fire, we would be wise to investigate and not dismiss the news just because they are a child.
Tommy Douglas, the father of Canadian Medicare, said:
“I want to say that I think there is a value in having every family and every individual make some individual contribution. I think it has psychological value. I think it keeps the public aware of the cost and gives the people a sense of personal responsibility.”
Tommy Douglas, the father of Canadian Medicare, said:
“I want to say that I think there is a value in having every family and every individual make some individual contribution. I think it has psychological value. I think it keeps the public aware of the cost and gives the people a sense of personal responsibility.”
Excellent. Thanks Gerry