© 1999  Karen Selick
Socialized Medicine--One Size Fits None
An edited version of this article first appeared in the February, 1999 issue of Canadian Lawyer.  If you wish to reproduce this article, click here for copyright info.


Socialized Medicine--One Size Fits None

Andrew Sawatzky, the elderly Manitoba man whose wife went to court to fight the "Do Not Resuscitate" order placed on his hospital chart, is probably part of a fairly small minority.  His wife says he wants resuscitation if he has another stroke, even though the attempt might fail or leave him permanently unconscious.

I discuss these life-and-death issues frequently with clients when preparing powers of attorney. The vast majority recoil from the thought of becoming brain-dead husks on permanent life support.  Most say that if their doctors pronounce further treatment futile, they would rather accept the verdict and "die with dignity."

But what’s right or wrong in cases like this can’t be determined by public opinion poll.  It doesn’t matter what 99 people would choose, if the hundredth person wants something different.  The question still remains:  what should be done about Mr. Sawatzky?

To me, the ethical principles that should be applied are simple.  Everyone should be free to conduct his life however he pleases, so long as he leaves others free to do the same.  It’s wrong to use force—including the force behind our court system—to bend someone to your will, except to enforce a contract the other person previously agreed to.

The Sawatzkys, if they want heroic and possibly futile measures taken, have the right to try and procure such services.  But they don’t have a right to force any particular doctor, using the court as their big stick, to render those services.  If their current doctors and hospital genuinely believe it’s unethical to provide them, all the Sawatzkys can do is look for someone who believes otherwise.

The doctors and the hospital, on the other hand, have no right to impose their will by force on Mr. Sawatzky.   For example, they can’t refuse to let him leave if he finds an alternative treatment centre that is willing to comply with his wishes. 

But there’s a good chance he won’t be able to find one.  Now the secret, unmentionable side of the problem must finally be broached: money. 
The hospital couched its objections to further treatment in humanitarian terms, but they rang hollow to me.  So what if resuscitation attempts might fail?   Why not just try and see?  And how can it be "cruel" to treat someone when he understands the risks and still wants the treatment?  People make decisions to undergo risky medical procedures every day, and hospitals don’t overrule them because the operation might fail or the outcome might be tragic. 

If life support machines grew on trees, and an infinite amount of money earmarked for paying doctors’ salaries and hospital expenses fell like manna from heaven, we would not be having this debate.  Under those conditions, who would deny Mr. Sawatzky his resuscitation request?  Why not give him every conceivable chance of survival if he and his wife are willing to risk the possible negative consequences?  No-one else would be harmed by it. 

It’s only because medical equipment and human labour are scarce resources that hospitals must make choices about when to use them.  And it’s the albatross of socialized medicine around our necks that makes us insist upon a one-size-fits-all solution.  If we give Mr. Sawatzky an unlimited amount of futile medical treatment, how can we ever deny it to anyone else?

Suppose Canadian law permitted the hospital to say to the Sawatzkys, "Okay, we’ll furnish heroic measures, provided you pay all the costs—including the cost of all the extra years of hospitalization if he enters a permanent vegetative state."   This might well make the Sawatzkys change their minds.  Mrs. Sawatzky might not be willing to risk being destitute for the remainder of her life.  Her husband probably wouldn’t wish to see her sacrifice herself this way.  But if the Sawatzkys themselves, the only people who would derive any benefit from the procedure, were unwilling to pay, why should strangers, many of whom would choose death for themselves in comparable circumstances, be forced to? 

If people had a choice about what medical care they wished to buy or insure against, different people would choose different plans.  Some might purchase the deluxe package—heroic measures and full life-support to the bitter end.  Others would buy just the basics—painkillers and a quick death.  Neither choice is wrong, but the price tags would be very different.

Ironically, those who choose the basic package might end up living just as long as those who choose the deluxe.  The money saved on health insurance would allow them to take more leisure, or improve other aspects of their daily lives, or relieve some of their stress, all of which might let them live longer and healthier lives.

This is not a choice the state should be making on our behalf.  But socialized medicine takes our choices away—both as to how much we wish to spend, and how much we wish to receive. 

There is no moral solution to the Sawatzky case, because we’ve been dragooned into a system where moral behaviour—free, voluntary trade—has been outlawed.  The remedy is not to make further bad law in each new case—it’s to scrap the whole, immoral system.

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June 20, 2000