Doing right

Every occupation, it appears, has its difficult side. When I have been presented with a tricky situation, I have often thought how much simpler it would be to chuck the job of medicine and go back to the land—sowing the seed and reaping the harvest. No tough choices; simply accepting what nature throws your way.

But then I am reminded how farmers must deal with water contamination, drought, controversy over genetically modified seeds and genetically modified food, foot-and-mouth disease, and BSE. Most fickle of all, primary producers must accept trends in consumer tastes. Sometimes this is easy to do, but often it is not—I’m reminded of the bumper sticker on the back of a cattle train in the Northern Territory of Australia, which gently suggests “Eat More Beef, You Bastards!” Accepting what nature throws your way is easy in theory, but tough in practice.

In the past few months, virtually everyone involved in health care delivery has been faced with dilemmas of one kind or another, and many remain unresolved. The ultimate in manipulation strategies—partial or complete withdrawal of services—has been resorted to by physicians, by nurses, and by members of the Health Sciences Association, with variable effect. It is surely inconceivable that those who withdraw services do so without enormous soul-searching, knowing that they may expect a hostile response from the general population and charges of unprofessionalism from the government. In most cases, withdrawal of services is nothing more than a gesture signaling frustration, and it is the response of others to the withdrawal that provokes defiance and a militant attitude. Keeping rhetoric to a minimum, in an atmosphere of reason, is critical for resolution of such dilemmas.

In resolving dilemmas in medicine, we can usefully apply a number of strategies based on the cardinal principles of bioethics. It seems to me that these principles should also be considered in trying to resolve our struggles with resources and remuneration—so that we maintain civility and remember the big picture. They won’t necessarily resolve the problem, but they do help direct any discussion to where a resolution might be found.

The principle of autonomy has governed the direction taken by most democratic societies, and being Canadian implies that we are free to do whatever we want—including determining how and where we obtain medical care. Being a Canadian physician implies having professional freedom, although there is a fine line between self-determination and selfishness. Beneficence is the reason why the medical profession exists, although Hippocrates insisted that non-maleficence should take precedence over our wish to do good things for others. Each of these principles can be seen to have some relevance to delivering health care.

The fourth principle, justice, is not only relevant to health care delivery, but also contentious. The concept of justice in health care delivery implies that all participants in a society will be treated equally and with consideration of the effects of delivery on providers and consumers. Without thinking too hard about this, the current dissatisfaction with the Canadian system arises from a sense of injustice on both sides of the system.

Autonomy, beneficence, and non-maleficence are areas in which we don’t want to see change. We want to do what’s right. But problems in the area of justice suggest that the system (the Canada Health Act) must be revised. I never thought that I would be saying that—and it seems like I’m not the only one saying it.

—TCR