© 2002 Karen Selick
Go Ahead, Make Our Day
An edited version of this article first appeared in the December 17, 2002 issue of The National Post.  If you wish to reproduce this article, click here for copyright info.


Dissecting the Sacred Cow Called Equal Access

In the flood of commentary that both preceded and followed the Romanow report, one subject has remained virtually immune from attack:  the “equal access principle” which Mr. Romanow considers an indispensable feature of the health care system.  Some critics have noted that Canadians do not actually have equal access to health care, but few people ever question the proposition that every individual deserves equal access.

Two lines of thought seem to underlie the proposition that all Canadians are equally deserving.  First, there’s the notion that illness or injury is a chance misfortune that descends upon innocent victims at random.  Since any of us might be next, the reasoning goes, we should all be willing to grant to those who are actually afflicted the kind of care we ourselves would want if our turn ever came. 

Certainly there are cases in which this description of illness is accurate.  Anyone can be hit by lightning, by a drunk driver, or by influenza, through no fault of his own.  But a huge proportion of our health care bill is generated not by isolated, random, unforeseeable events like these, but rather by a long pattern of deliberate behaviour on the part of the patient himself.  Individuals who smoke regularly, who drink to excess, who habitually overeat, or who shun exercise are all responsible in some measure for their diminished health.

Is it fair that those who conscientiously maintain their health and add little financial burden to the system should have to pay for the much higher health care expenses of those who recklessly squander theirs?  Or, adding insult to injury, that the conscientious individuals should have to wait in line for their annual check-ups behind the reckless ones making their weekly visit to the doctor for a preventable condition?

The second idea underlying the notion of equal desert is that described by ethicist Arthur Schafer, writing in The Globe and Mail in September: “…most Canadians continue to defend the egalitarian assumption that, rich or poor, all lives are of equal worth.”

Perhaps most Canadians do indeed defend this assumption. Their numbers, however, should not prevent thoughtful readers from scrutinizing it.

Are all lives of equal worth?  The concept of “worth” presupposes the existence of someone who is doing the valuing.   Every person values things from his own perspective.

My life is worth more to me than the life of convicted murderer Paul Bernardo.  Many people would, I hope, agree with me.  However, it’s not necessary to choose a notorious criminal in order to make this point.  My life, and the lives of my family members and friends, are worth more to me than the lives of the strangers down the street, or the MPs in Ottawa.  I have no compunctions about saying this.  Anything else would be a patent lie.

The only sense in which justice demands that we be egalitarian is that each of us must grant to every other individual the right to feel the same way about himself or herself.  I acknowledge the right of the strangers down the street to feel that their lives are worth more to them than mine.  I could not rationally expect them to feel otherwise. 

So how, then, can we ever arrive at some objective, conclusive ranking of the worth of every member of our society?  We can’t, of course.  It would be impossible to reach a consensus.  However, this is not the same as saying that every life is of equal worth.

The closest thing we can use as a proxy for ranking the worth of any particular person to society as a whole is to look at the cumulative rewards that the other members of society freely bestow upon that person.  In a developed economy, money is one of the mechanisms by which members of a community cumulatively express their appreciation of the value that each individual contributes to them.   

For instance, not being a sports fan, I personally place little value on athletic superstars.  Still, many of them earn multi-million dollar salaries annually.  This wealth, freely contributed by millions of enthusiastic sports fans who pay to see them play, indicates that the services the athletes provide are more highly valued by society collectively than the services that I provide.

When we forbid people from using their wealth to purchase medical treatment, we are in essence retracting society’s collective acknowledgement of that person’s value to it. 

We are also undermining the natural incentives for individuals to try to please their fellow man.  Why put forth the effort to earn a lot of money if you’re not permitted to buy anything better with it than someone who chooses not to work at all?

Admittedly, the correlation between wealth and service to others has never been perfect—and these days, it is becoming increasingly tenuous as half our income is taxed away by the state and bestowed upon its employees and cronies.  These recipients would rarely earn as much in a free market—that’s why the state has to coerce us into paying them.  Nevertheless, to the extent that markets are permitted to operate, there is truth in the proposition that those who earn more do it by satisfying the wishes of their fellow man in greater measure.

But regardless of how much a person earns, a further case can be made that not all are equally deserving of health care largesse.  Money accumulates in an individual’s hands not only because of how much flows in, but also because of how much flows out.  Two people with modest but equal incomes can have very different spending habits.  Is it fair that the person who spends his small surplus income at the racetrack should get the same quality and quantity of health care as the person who saves his equally small surplus income for emergencies so that he will be both willing and able to pay for his treatment?

The more zealously we insist that everyone is entitled to equal health care regardless of how they behave, the more we undermine responsible behaviour and increase our total health care bill.

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February 6, 2003