Ways, means and ends: debating health care reform

In the current debates on health care reform, 2 sorts of assertions vie for attention: claims to fact, and articles of faith. Fact: the current rate of growth in health care costs is unsustainable. Faith: our health care system needs “remodelling, not demolishing.”¹ More evidence has been conscripted into the pessimistic service of fact than of faith. No matter, say the champions of medicare: it's time to put our values back in order.

In consulting with the nation on facts and values, Roy Romanow has made a point of dwelling on the latter. The impeccable bedside manner of his interim report — its inclusive language, its respectful articulation of the cardinal points on the opinion compass — soothes our anxious understanding that imperfect changes to our imperfect system will come. The implicit hope is that, if we give our values a good brushing and a bit of polish, we will protect them from the grime of economic necessity. We'll still be wearing our comfortable old shoes — say, accessibility on the left, portability on the right — as we walk to the publicly financed and regulated private clinic.

But there is a troubling disconnect between talk of values and talk of reform. Time was when “reform” had to do with societal transformation, not fiscal restructuring. “Reform” invoked such matters as better working conditions for the poor and widening the franchise. Now, reform has acquired postindustrial preoccupations, like consumer choice and provider accountability. Although these notions imply some idea of social goods, the dominant language of reform is the language of the market, of efficiency and cost-effectiveness, of the discipline of competition. It is a language of ways and of means, and it has a habit of disguising itself as the language of ends.²

Efficiency, we are told, is not merely a desirable attribute, but a defining Canadian value.³ This is rather curious: in the dystopias of Orwell and Huxley efficiency is highly prized, too. Efficiency is not necessarily the ally of equity,² even though its intent is to make limited resources go further. Choice is another such value. Why would we argue against the merits of choice — unless we consider that choice is often congruent with privilege. User fees, privatized services, medical savings accounts: all of these devices may increase choice — for those who can afford it. The trouble is that health care is such a complex and fatally human institution that any attempt to “rationalize” any part of it has unintended consequences.

What are we aiming for in medicare reform? More efficiency? More caring? More accountability? More choice? We asked notable Canadians of various callings and ideologic persuasions to contemplate the ways and means and ends of health care reform. How can our society attain health, in the broadest sense? In these essays, some will speak of goals, others of approaches, and others, like Steven Lewis in this issue,⁴ (page 1421) of governance. Inescapably, these essays are also about values — old, new, trusted or treacherous. We leave it to the reader to put them in order. — CMAJ