Equal care: Is it possible?

That all men are equal is a proposition which, at ordinary times, 
no sane individual has ever given his assent. —Aldous Huxley

For many of our professional associations, health care transformation translates into more government dependency, as they seek ever more resources from taxation. For most physicians, I believe the opposite is true. The emphasis (for example at the last CMA General Council) on seeking equality, or equity, raises the question: what do the terms really mean?

We live in the third most sparsely populated country on earth. Equal care across the land is a practical impossibility. Metropolitan dwellers in need of emergency critical care for catastrophic illnesses will always have better access and outcomes than those living in smaller communities. 

There are variable complication and survival rates for treatments in different hospitals. Individual physician expertise and success rates vary. Physicians have insider knowledge of whom we perceive to be the best doctors. Not everyone has that knowledge and, even if they did, might have difficulty making use of it. Equality is a myth, and will remain so, until all diagnosis and treatment is automated and performed by universally available intelligent robots.  

Equitable distribution of resources does not, of course, correlate with equal. Equitable availability of health care introduces the concept of fairness and thereby subjectivity. It raises ethical questions relating to lifestyle-induced health problems (for example, smoking, alcohol, drugs, boxing, hockey, and so on). Professional athletes risk injuries in order to earn multi-million-dollar paychecks.

An oncologist recently pondered the issue of new life-prolonging drugs for patients with terminal illnesses. Who will authorize treatment costing $20000 per week for a 3-month life extension? Will those who are not offered the treatment have the option of paying for it? Equality is maintained when either everyone or no one gets the treatment.

Tommy Douglas wanted good basic care for all, but did not set a ceiling on what citizens could access for themselves. When his daughter (actress and medicare supporter Shirley Douglas) received poor nursing care in the public system, he hired private nurses to care for her.

Early in 2014 (after a 5-year wait), these and similar issues will be placed before a judge of the BC Supreme Court. Such arguments will be heard in the context of a constitutional challenge to inappropriate rationing of access and care in Canada. We expect an impartial, evidence- and fact-based decision. It is unfortunate that we as a profession, and our governments, have abrogated our responsibility for leadership in achieving transformation of our health system. We must now depend on our legal system to enforce necessary change. 
—BD