Selfishness is not a virtue in medicine, even if Brian Day says so

The B.C. Supreme Court is hearing a case that could privatise all or part of Medicare and open the floodgates to American private insurers who are clustered, salivating at the 49^th parallel. They are hoping for a $40 billion windfall if orthopedic surgeon Brian Day wins his case.

There is one simple principle at stake in this landmark lawsuit.

Imagine your boss says “I’ve got two jobs I’d like you to do. They’re for different clients, but otherwise they’re the same in every way – except for one thing. The second client has agreed to pay you an extra $500 to get it done.”

Which job would you do first? Which would you do with more enthusiasm? Which one would you do with a smile on your face and a warm feeling inside, as you privately contemplated all the things you could buy – or pay off – with that extra five hundred prunes.

And if your boss — or your government, or your neighbour next door, or your union, or anyone at all — presented options like this to you on a regular basis, which direction would you tend to favour given those perks, the extra material benefit that would help you out financially and make life that little bit easier?

The answer is clear for the overwhelming majority of us. We might well drift towards favouring those tasks whose material rewards are greater, because “he who pays the piper calls the tune.” Our minds, generally speaking, are drawn towards “free” money or “free” benefits – meaning benefits that come to us seemingly without a penalty of any sort.

But of course the scenario above tells only half the story.

We don’t know what this process is like for the person supplying us with the extra cash. Is coughing up that extra dough a hardship for them, or a piece of cake? Are they rich like Croesus, or poor and disabled and on a fixed income? Do they like the system that puts them in the position of paying extra to get service, or do they deeply resent having to pay a premium that another might not?

All those questions fade away as we take our bonus cheque off to the bank, and as we look around for the next client/customer/patient who is willing to sweeten the pot in return for our services.

If we're being honest, I think most of us can see ourselves being drawn into this drama.

But most of us would also feel a growing sense of disquiet about the person who is forced to wait longer for help because he or she couldn’t afford to pay extra. We would perhaps feel some vicarious resentment, as the service provider slides towards clients who would pay that bit extra — especially if our health or well-being was likely to be seriously compromised.

In Michael Moore’s documentary film Sicko there is a compelling scene in which a man is interviewed after having his thumb, index and ring fingers amputated in an accident. He has no publicly funded health care insurance and, if he's going to get treatment, he has to pay out of pocket. He can’t afford the thousands of dollars needed to re-implant all of his fingers so he is trying to decide which is the best one to get put back. He calmly describes a pragmatic discussion with an orthopedic surgeon, who lays out the advantages and disadvantages of re-attaching each separate digit. The surgeon informs him that if he can only afford one re-implantation, getting his thumb re-implanted, while somewhat more expensive, will give him back a hand grip, whereas re-implanting the others will not.

The man opts for getting his thumb re-implanted.

Brian Day, and his friends in the U.S. private health care business, will not be able to recreate this exact situation in Canada. Day is not proposing that publicly-funded medicine in this country be completely supplanted by private care – that would be professional suicide, as he knows the US system is more costly, less efficient, and grossly inequitable – as the scene in Michael Moore’s film reveals.

But Day is also ignoring human characteristics – how that current of self-interest that lies deep inside every one of us can grow into a broad river of self-centred greed in all but the most ethically grounded and psychologically secure among us. For the average doctor, who is very much like the average person in the rest of society, the temptation embedded in a pay-extra-for-extra-service system will be very, very hard to resist.

And systemic unfairness will be the result.

The only way to counteract this wholly unsatisfactory outcome is to build – or maintain – a system centred around the principle of fairness.

But if we want fairness, then we must build and maintain a system that formally discourages unfairness, a system that disallows the expression of personal vested interest on either side of the equation. Leaving it up to individual decision-making is not enough.

We must build and maintain a system that says to patients: "If you seek our services, then you will receive them according to your need for help, or for protection against illness, or the repair of injuries from an accident, or to relieve your suffering and distress – and not according to your ability to cover the extra fees that will induce a doctor to treat you first.”

We must build and maintain a system that says to doctors: “You are mandated to help people who come to you, not because it will profit you more to treat some than to treat others, but according to the urgency of their condition, their degree of suffering, and the risk to their short and long-term health posed by their condition. For this you will be fairly recompensed.”

I have heard Brian Day speak, and I have read his written remarks. He is passionate, enthusiastic and energetic beyond his years.

But in my opinion, he is fundamentally and dangerously naïve about human nature, including his own.

Like the proponents of Reaganomics and the “trickle-down theory” of economic development, in which the very rich must be coddled because they will be naturally moved to share their wealth with the less fortunate by creating vast numbers of meaningful, well-paying jobs, Day’s understanding of what moves the human heart and mind is flawed. Instead of Reaganomics and the trickle-down theory producing meaningful work for many, we have a vast array of demeaning and ill-paid “entry level” work, and a corporate mindset that contemplates vast disparities in income with bland indifference.

Similarly, Brian Day’s intent – to allow doctors to slip seamlessly into extra-billing for otherwise insured services -- is centred on the same naiveté. It will lead directly to increased unfairness in health care.

I must admit, I hope he loses his case.

Whatever its flaws, Medicare deserves a better outcome than victory for the forces of selfishness.