In Part I of this essay, we discussed how Canada committed the fatal error of proclaiming that health care is a right and ended up with socialized medicine. In Part II, we will now discuss the long term consequences of this decision. Perhaps, the U.S. can learn from our mistake.
The Laws of Supply and Demand
To begin to understand some of the long term consequences of declaring medical care to be a right we must understand exactly what happens when a society makes such a declaration. What is it that actually takes place when what is clearly a product is considered to be a right? Other than giving liberals and conservatives alike the warm fuzzies, what is really going to occur?
The critical event is the breaking of the direct economic link between the producer of health care, the doctor, and the consumer of health care, the patient.
With the severing of the economic link between producer and consumer, a very important financial check on the system was lost. The patient no longer had to be concerned about being financially responsible for his or her own health care. He could profess a need for virtually anything available and the state would provide it. The physician no longer worried about whether or not a patient could pay for any given test or treatment. He could order and do anything for the patient and the bill was paid. Hence with the advent of socialized medicine concerns with respect to costs became, on an individual level, irrelevant.
What does such a situation lead to?
At any one time the resources of society are finite, yet the potential demand for those resources is infinite. Hence an ongoing concern of every society is how to allocate those resources. In free societies this is done through prices.
It would be nice if every one could drive a Rolls Royce and live in a mansion, but the cost of such items keeps them available only to those whose productiveness meets their cost.
With health care being a right, and costs no longer thought to be important, everyone had access to Rolls Royce health care. It did not matter if you were a totally non-productive lay about, or if you were the most industrious person in the land, you had equal access to all that the art and science of medicine had to offer.
Ultimately however the bill has to be paid. Even if at an individual level society wants to pretend that costs are not important, it cannot escape the fact that there is no free lunch. A fundamental law of economics came into play at this point, the law of supply and demand. With demand for medical care rising dramatically, yet resources not being able to keep pace, the only possible result could be and has been dramatically rising costs. A look at the percent of GNP that Canada has spent on health care over the past quarter century shows a steeply rising curve which is a direct expression of this law.
For example, what would happen if we declared food to be a right? Indeed, using the socialist's line of thought, this would be even more sensible than health care, as the need for food is a lot more immediate. Just think, we could all dine on filet mignon and truffles and not have to worry about the costs. But the costs are there regardless, and with everyone consuming expensive food, the government would find costs going through the roof.
Once this dramatic rise in costs occurred, the government had to look for ways to control costs, price controls. Even the most addled socialist recognized the non-sustainability of the situation. The politicians could not reverse socialized medicine as that would be political suicide. Hence the only way open to them is to control the medical profession, which is what you and I are experiencing today.
Why did the socialists want to break the economic link between the doctor and his patient? Socialism boils down to the public, i.e., state control or ownership of the means of production and the creation of a centralized planned economy. The idea that medicine is a commodity produced by profit seeking entrepreneurial physicians working in a free market, and purchased by their patients, is antithetical to the socialist world view and had to be destroyed.
We often hear that it is technology that is to blame for the rise in costs of health care. This can only be true if the state declares that everyone has a right to it. For instance, if someone invents a new diagnostic tool that costs a million dollars per unit, that act does not in itself raise costs. But if the state declares that the people have a right to it, and that we need a given number per capita, health costs will soar.
Another key consequence is the necessity of having unimpeded government involvement in health care once it is considered a right. The defense of rights, individual rights, is the one legitimate purpose of government. As Thomas Jefferson so eloquently put it, "....to secure these rights, governments are instituted among men, deriving their just Powers from the Consent of the governed."(1) Hence once health care is thought to be a right, society is going to require that government be involved.
And what is government? At its root, government is force. Thus if health care is a right, government will forcibly ensure that everyone has access to it.
What flows from this is the complete intellectual disarming of the medical profession. After all, if the government forces the doctor to work somewhere or dictate to him what his work is worth, who are we to complain? The government is simply ensuring everyone has access to their health care rights.
A much less obvious but potentially very destructive consequence of society looking upon medical care as being a right is the ruination of the principle of the rule of law.
Any society, even totalitarian ones, must have a system of laws. Without them any society would rapidly deteriorate into chaos.
The rule of law, however, is more than just a system of rules that people in society live by. As F.A. Hayek put it, the rule of law is supposed to be like "sign posts on the road."(2) Just as sign posts will tell you where you will end up depending upon which road you take, the law is supposed to inform people in advance what course of action the state will take for any given behavior.
In socialist states however, the central planners take down all signs except one, which reads, 'you will take this road.' The people's ability to determine their own actions is vitiated, and despite the superficial appearance of lawfulness, the rule of law is destroyed.
An example of this in the context of the current discussion was provided by the government of Ontario after the passage of the law banning 'extra billing.' The government made statements to the effect that Bill 94 was now the law of the land and had to be respected. It was obviously appealing to the principle of the rule of law, but as is now clear its claim to this principle was fraudulent.
Working Physicians Are Blamed
One has to wonder how it is that despite the profession's intense dissatisfaction with the current state of affairs it continues to look after its patients. Consider the government, the press, and to a great extent, the very people we look after, continuously denounce us and impose further limitations on our professional lives.
Imagine what would happen if General Motors informed the Canadian Auto Workers Union that it had discovered its costs were up, which was clearly the workers fault, and that the company would therefore be clawing back one month's salary from the workers. Such an announcement would be greeted with guffaws.
Yet the government of Ontario, during the mid-1990s, saddled the medical profession with complete responsibility for any increase in costs and as a result clawed back 10 percent of every bill submitted by physicians to the extent that it confiscated over $800 million dollars of the professions work. Despite this, here we are, day in and day out, looking after our patients.
So how is it that the medical profession continues to perform?
The answer to this question was provided by Ayn Rand when she identified the principle known as the sanction of the victim.(3) One of her keener insights, this principle explains how it is the victims of the socialists, or collectivists of any stripe, are actually their own worst enemies. In brief it is by virtue of the willingness of the victims to serve their ends that the collectivists are able to succeed. Indeed in order to succeed they must have the victim's consent.
Consider the debate over "extra billing," or any other time the medical profession has fought with the government. During the debate the Peterson government made the statement that it could not believe physicians would do anything to hurt their patients. Reflect on that statement for a few moments. Here was a government that was bound and determined to revoke the physician's right to contract for services on the free market, which was what the debate was really about. This would be an unthinkable intrusion of the state into physician's lives in a free society. Yet, here was the government relying on the unwillingness of physicians to see any harm come to their patients to prevent us taking the necessary steps to stop the legislation --- i.e., the complete withdrawal of services.
It is our caring for our patients that is arguably the profession's greatest virtue; yet, here it was, and is, used as a means to disarm and control us. Imagine doctor, the very best within you is used as a means to control and subjugate you. A rather pernicious weapon is it not?
What Physicians Must Do
Clearly a fundamental shift must occur in how medical care is delivered in Canada. But before this can occur, there must be a fundamental shift in how this profession views itself and its relation to society. This change is at once both easy and difficult. It is easy, as it requires but a change of thought on our part; but it may also be difficult, as it will require a radical rethinking of our relationship with our patients.
This intellectual change must begin with the realization that what we do, the thing we produce known as health care is nobody's right. It is the product of our lives and belongs to us. It is clearly something we value, otherwise we would not produce it. Should others wish access to it, they must offer value for value. Professing need does not lay a claim on our product and thereby our lives.
Once this is clearly understood by the profession, what must then happen is the restoration of the direct economic link between the doctor and his patient. This will mean the restoration of the market place as the means of delivering medical care in this country. All government involvement in the delivery of health care must cease. This will likely take quite some time; thus, the aphorism that it is easier to get into trouble than to get out of it applies here. However, the notion that medical care is a right to be provided to the public by our profession at the behest of the state must be eradicated. Once this is done, we will find ourselves in charge of our profession again, and we will be able to use the market to provide good medical care in Canada as well as in the United States.
This does not preclude the use of private insurance plans in the delivery of medical care. Indeed the pooling of risk is a tried and true method of distributing the costs of expensive commodities such as health care. The ideal method will in fact likely involve a multi-tiered insurance program whereby people buy the level of insurance that they can afford. We would do well, however, to avoid the managed care fiasco taking place in the United States, where bureaucrats who do not have the qualifications necessary to apply a band-aid, are dictating to doctors how to do their job.
What about the poor? The truly destitute will be looked after by voluntary charity. There is more than enough benevolence in the human spirit to look after the honest poor.
Do not be deterred by the socialist straw man known as "two tiered medicine." The distribution of wealth in society falls on a continuum resembling the bell curve, and the amount of medical care available will also resemble such a curve.
Do not be swayed by the socialist lament that under free market health care some people will be denied access to health care. This is an equivocation. The only thing anyone would be denied access to in such a system would be the unearned.
And it is imperative that we never, ever, under any circumstances, allow our virtue to be used as a weapon against us. Recall the words of Ayn Rand: There comes a point, in the defeat of any man of virtue, when his own consent is needed for evil to win --- and that no manner of injury done to him others can succeed if he chooses to withhold his consent.(4)
If we avoid this mistake, we cannot lose.
At this point the reader may be wondering how this degree of change could possibly be brought about. Indeed, one often hears the words "impotent" and "helpless" applied to our profession when discussions about controlling our own destinies are held.
The profession will get no help from any government. The choices offered to Canadians by the main political parties are merely variations on a theme of socialism, and all remain firmly committed to socialized medicine.
Parenthetically, the idea that Canadians are offered any fundamental options by our main political parties is the Canadian Big Lie. All of them only offer variations on collectivism and statism, which is manifest in the Canadian version of socialism. We hear that from time to time the political pendulum will swing back and forth between the political left and right, but in Canada, and indeed the West in general, the pendulum has been so corrupted that as it swings back and forth, and reaches the supposed opposite political extremes, it in fact finds itself at the same place, collectivism.
The public, for the most part, still does not see the approaching cataclysm, and continues to think that medicare (i.e., the Canadian government health insurance) is wonderful. Indeed the public seems quite content to do what is necessary to retain medicare, including enslaving our profession.
Within the profession, the leaders of our professional associations have, in the not too distant past, been heard chanting collectivist mantras, and appear to have joined the other side. Even organizations which have sprung up in opposition to the Ontario Medical Association still clamor for "an excellent government-run system which provides all necessary services."(5) Hence change will have to come from the individual physician.
However, what must happen to end socialized medicine in this country is actually very, very simple. All that is required is for the profession to say, enough!
Believe it or not, we actually have the upper hand. Remember: nobody else can do what we do. If our services are withdrawn, there is no one to take our place. There will be a few physicians who will continue to toil for the glory of the collective, but by and large, if we stop working, the system grinds to a halt. The physician is the keystone in the arch of medical care. If we leave, it cannot but fall.
On a purely pragmatic level, we should all withdraw from medicare and deal with our patients directly. Set up accounts with the major credit card issuers and bill patients when seen. Do not help the government do anything with respect to medical care. They are likely to try to keep the system going but, without our expertise, they will make a hash of it. They will likely attempt to legislate us back into the system, but these efforts should be ignored (civil disobedience has a distinguished and well established intellectual basis).
The transition to a free market health system will have to be done with extreme caution. Its supporters can be expected to give up socialized medicine on their death beds and not before. They will do everything in their power to thwart this change. They may, for instance say, "OK, you well-to-do types can have your private system but we will still keep a public system for the rest of us." While this may seem at first glance to be a good thing, it is not.
Consider that all government debt in Canada stands at about $700 billion dollars. That debt must be paid off. Thus for the foreseeable future the productive members of Canadian society, a segment that includes us, will see the confiscatory levels of taxation we are now subject to continue well into the future.
Hence, if we agree to such a change, even as a first step, our expenses will rise to pay for the new system; yet, we will see no reduction in costs incurred paying for government programs and debt, while the fundamental problems associated with the public system will not have been addressed.
If the profession does muster the courage to make such a momentous change there will be a confrontation with the state that will make the "extra billing" debacle look like a walk in the park. The press will launch into torrents of vilification that will make their previous lies and equivocations look like compliments. And yes, in the short term, people are likely to be hurt. Maybe me, maybe you, maybe our loved ones. Before you balk at those statements, try to think long range.
By now it should be clear to you that our current course can only lead to disaster, both for us and our patients. In the long term many more people are going to be hurt by our failure to change the system than those hurt in the short term by that change. I recognize any change that involves any degree of hurt for anybody will be an intensely painful one for this profession. Indeed, given what we do, caring for our fellow human beings, a change that hurts people, however short term, may render us incapable of effecting that change. But if we do not alter our present course, know that in the long run all of us will be grievously hurt by the continuation of socialized medicine.
The state should be held accountable; they forced the issue trying to enslave us.
The possibility of the state using force against the profession is high, and it is not too far fetched to think of doctors being jailed for attempting these changes. When one revolutionizes a society this is unfortunately an all too common occurrence. The state will perceive itself as being threatened, and with the profession having disabled its most effective weapon, the profession's own sanction, it may react with the only weapon it has left, the use of force. This is not all bad; even the sublime Thomas Jefferson recognized "the tree of liberty must be refreshed from time to time with the blood of patriots and tyrants."(6)
Can we succeed? Yes, we need but make one, albeit difficult, decision, and we regain control of our lives and our ability to provide good medicine to Canadians. But we must enter the fray with absolute moral conviction on the correctness of our position. Too often those who fight our socialist tormentors make the mistake of surrendering the moral high ground to them. Comments to the effect that socialism sounds good in theory but will never work are profoundly mistaken. It is true that it will never work, as the record of the past century shows, but worse than that, it is a malevolently immoral doctrine, as it is predicated on the use of force to achieve its goals.
The battle is likely to be long and bitter, but remember the words of Thomas Paine, the firebrand whose ideas served as the catalyst for the American revolution: "What we obtain too cheaply, we esteem too lightly."(7)
And Lenin once suggested that to socialize a country one must socialize its medical system. Perhaps the extirpation of socialism from a country, our country, can begin by ending socialized medicine everywhere. Certainly Canadians seem to have had enough of socialism, and the level of discontent is now reaching the flash point. Perhaps, if the medical profession takes a principled stand on this issue, physicians will become the spark that ignites the storm that clears the socialist miasma that wafts ever foul across this land.
1. Jefferson T. Declaration of Independence, Philadelphia, PA, 1776.
2. Hayek FA. The Road to Serfdom, Chicago, IL, 1944.
3. Rand A. The Sanction of The Victims. The Objectivist Forum, New York, NY, 1982.
4. Rand A. Atlas Shrugged. New York, NY, 1957.
5. The Ontario Physician's Alliance Newsletter, May 1996.
6. Jefferson T. Letter to William Stevens Smith, 1787.
7. Paine T. The American Crisis, No. 1, 1776.
Dr. Aubrey is an internist and rheumatologist in Newmarket, Ontario, Canada. His e-mail is firstname.lastname@example.org.
Originally published in the Medical Sentinel 2001;6(2):57-60. Copyright ©2001 Association of American Physicians and Surgeons.