Ethics and Single Payer Healthcare

Ethics can be described as the art of doing the right things for the right reasons. Recently, a family doctor (Dr. Brcic) writing for the Tyee claimed that private for-profit healthcare in BC had egregious ethics because the finances of for-profit care were obscure, accessibility of for-profit care was limited, and that individuals coping with pain and illness were vulnerable.

However, in claiming that the ethics of for-profit care are egregious, it would be a large error, an egregious one, to assume that the ethics of single-payer care are any better. Perhaps what is striking and often ignored are the numerous ways in which conflicts of interests and breaches of ethics occur because of the single payer system and how it is structured.

First, by prohibiting competition in the healthcare sector for medically necessary services and being the sole provider of those services, government is in a conflict of interest. It has a political interest in making it look like the system performs well. It has a financial interest in limiting the amount of money spent on services provided. It has both a political and financial interest in limiting accountability for medical error and system failures. It is fair to say that many measures of the system are cherry picked to demonstrate good performance or obscure poor performance. The system does not measure real wait times. The system does not measure care demanded but not received. The system takes credit, for things that are likely the result of other socio-economic changes. Holding the system to account for medical error, or even medical malpractice is notoriously difficult in Canada. Is it particularly ethical that a person wanting cosmetic surgery likely faces a much shorter wait time than a person in need of pelvic floor repair? Is it particularly ethical that a consumer who buys a faulty car likely has more recourse than a victim of medical error?

Second, by making doctors accountable for system sustainability it puts doctors in an unenviable position of being in a conflict of interest when it comes to the best interests of individual patients versus the best interests of the system. Doctors need to be able to focus on the needs of their patients without worrying about the needs of a system.

Third, a single-payer system often results in an arbitrary violation of an individual’s right to medical autonomy. Rather than a person being in charge of what is done, and when, the system determines which choices are available and controls access. If a service is medically necessary, an individual is at the mercy of the system and the system’s assessment of the importance of the condition and accessing treatment. The system assumes (wrongly) that all individuals affected by a condition are impacted in the same way and fails to adequately reflect the wide variety of circumstances that individuals contend with. Further, because of the political nature of a single payer health system, conditions that have a high degree of stigma, or that affect few individuals may have a difficult time jockeying for a fair share of the resources needed. Is it particularly ethical to withhold access to treatment options and care, when the resources are available (upwards of 16 percent of specialists in Canada are unemployed, and more are likely under-employed), simply because public tax money is unavailable, but private resources are available? Is it particularly ethical to deny an individual the right to make medical decisions for themselves, because those decisions do not conform to the decisions the average taxpayer would make?

It is perhaps important to remember that politicians are not always renowned for their ethics, and it is an egregious assumption to declare that doctors are willing to abandon their ethics in favor of profit in a private system.