Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 14 - Evidence, May 11, 2000
OTTAWA, Thursday, May 11, 2000
The Standing Senate Committee on Social Affairs, Science and Technology met
this day at 11:10 a.m. to examine the state of the health care system in Canada.
Senator Michael Kirby (Chairman) in the Chair.
The Chairman: Honourable senators, we are here to continue our series of
hearings on the state of the health care system in Canada and, in particular, to
continue our hearings on our first volume, which is designed to give background
information and to bring people -- not only members of the committee, but those
who end up reading the report -- up to date on the series of facts surrounding
the current state of the health care system. We deal in that report with many of
the myths that are floating about.
Today, our first witness is Dr. John Millar from the Canadian Institute for
Health Information. He will present the highlights of his report, and then we
will ask him some questions related to that. Welcome, doctor, and please
Dr. John S. Millar, Vice-President, Research and Analysis, Canadian Institute
for Health Information: I apologize that I do not have French copies of the
report here. We just could not open that vault this morning.
I thank you for this opportunity to present some of the highlights of this
report to you. It is always gratifying for those of us who toil away in the
field of health information to have that information put before those who are in
a position to affect policy; I therefore welcome this opportunity.
This report came out on April 26. It is the first report that we have
produced. It is a report that was produced in partnership with Statistics
Canada. I should mention that the Canadian Institute for Health Information is
an organization that was set up in 1994 by the joint efforts of the federal and
provincial Ministers of Health to be an independent, non-profit organization in
the business of providing the best available objective evidence on two big
questions: First, how healthy are Canadians? Second, how well is the health care
system performing? Our intent is to answer those two large questions.
This particular report is the second of two. An earlier report in March,
issued by Statistics Canada, answered the question about how healthy Canadians
are. This report is talking more specifically about the health care system,
using the best available data and drawing on data at a variety of levels across
the country with an expert group that involved many illustrious academics and
practitioners across the country.
The first thing to draw to your attention in the report is that global
question of how healthy Canadians are. This is something that I am not sure is
widely appreciated. Over the past several decades, the health of Canadians has
been going up and up and up, surpassing all other countries. We are now second
in the world in terms of our life expectancy, second only to Japan. I would
anticipate before long that we will be number one. We are increasing at a rate
that is even more rapid than that of Japan, and Japan is experiencing some
Within that overall good news story about the health of Canadians, there are
some more disturbing stories, because certainly not all Canadians enjoy that
high level of good health. Aboriginal people, particularly, have a life
expectancy that is five, seven or twelve years different, depending on how you
measure it. Certainly, people in northern, rural, and low-income, urban areas
have a remarkably lower life expectancy than more affluent Canadians; so there
are some problems.
You have a copy of the particular report before you, honourable senators. It
does mention the life expectancy. It also goes into some details on the health
care system. It documents some of the changes that have been taking place. The
first and obvious change, outside of Ontario, is regionalization. Every other
province is regionalized now, and they are beginning to show signs of truly
being able to integrate services. That has been a major change.
The other major change is health care spending. I will show you some more
details on how the spending has changed. This slide shows the public and private
expenditures per capita in constant dollars. You can see that, through the 1970s
and 1980s, there were constant, real-dollar increases in health care spending
per capita, up until 1990, both in the public sector and in the private sector.
Looking at that top graph, you see that in the mid-1990s it plateaued and began
a period of real decreases in per capita health care expenditures in the public
sector, whereas below, in the bottom graph, you see that private sector funding
continued to increase unabated. That is the money people are paying out of
pocket and through privately purchased insurance programs.
The Chairman: I want to be clear that we are talking about apples and apples.
When you say "health care spending," can you tell me what services are
included in that?
I ask that because, for instance, federal money for health care goes toward
doctors and hospitals. I presume you are including a lot more than that. Is that
Dr. Millar: Absolutely, yes. I am including hospitals, doctors, some drugs,
some home care, some nursing home care and some mental health services. It is
mixed. The ones that are virtually entirely publicly funded are hospitals and
doctors. However, when you get into the question of drugs, it is a mixture. When
you get to home care, long-term care and mental health services, they are all a
mix of public and private.
The Chairman: In terms of health care spending, when you say "long-term
care," what are you including?
Dr. Millar: Everything.
The Chairman: In regard to nursing homes, you are referring to the full cost,
some of which is funded through both public and private monies. However, when
you say health care, you are including all those things.
Dr. Millar: Yes.
The Chairman: I ask the question because frequently from the federal side we
use the words "health care" but we do not really mean health care; we
mean medicare and hospital insurance.
Dr. Millar: This is much broader. It is all the public money being spent by
federal and provincial governments on the health services that they provide.
The Chairman: As well as all the private money being spent on things that
would remotely be called "health"; is that right?
Dr. Millar: Yes.
The Chairman: It is interesting to note that this report does not define what
you mean by "health care."
Dr. Millar: It defines the services. It shows what services are being
At the very top end of both those curves, you see white dots, which are the
estimates for the last couple of years showing that the public sector per capita
funding has begun to increase once again in 1998 and 1999. The private sector
continues to increase.
As a consequence, if you had taken a snapshot in 1997 looking at the per
capita expenditures in Canada compared with other countries, you would see, as
on this slide, that Canada is in fact fourth in the world among the G-7
countries in overall spending and is fourth in public sector spending. This is a
very interesting slide. The United States spends more per capita out of tax
dollars on health care than does Canada. They also spend more in terms of
private expenditures, privately purchased insurance and out-of-pocket
expenditures, than do Canadians. Yet, Canadians are almost the healthiest people
in the world, whereas the United States ranks twentieth-fifth in terms of life
expectancy. It is a curious observation, and there are various interpretations
around it. Some people look at this and say, "Obviously, we should be
spending more in the Canadian public sector." Other people say,
"Clearly, no. This reflects how efficient we are being. For those public
dollars we are getting such good outcomes." Other people say, "Part of
the reason we are doing so well is that we are spending relatively little on
health care, which frees up public money for other things like education and
social services that are health enhancing." There are various
interpretations of that.
There have been huge shifts going on in the way health care dollars have been
spent so that the amount spent on hospitals as a percentage has dropped
considerably. It is now at 31.6 per cent; it used to be in the mid-40s.
Physician expenditures as a percentage share have dropped, whereas the amount
being spent on drugs has been continuously increasing. Thus, that is now the
second major health care expenditure.
These changes in funding and the reductions in funding have clearly created a
lot of stresses in the system. It has been accompanied by a 25 per cent
reduction in hospital bed availability. There has been a shift over to more
outpatient services. There are many stresses that have gone along with that. One
of those is that public confidence has been eroded significantly. We certainly
have very well documented in this report that there has been less access to some
services, such as emergency rooms and some specialist services and procedures.
As a consequence of that and as a result of media attention to it, public
confidence has dropped quite considerably. As you can see from this slide, it
has dropped from 50 per cent or 60 per cent of people expressing confidence in
the system down to some 20-odd per cent, which is quite a dramatic reduction.
On the other hand, when you ask people who have actually been the recipients
of care, they express very high levels of satisfaction. That reflects the fact
that the provider groups, that is, doctors and nurses, despite all the stresses,
have been struggling to continue to perform to a high level. The performance
measures we have show that there are good outcomes. It is an interesting
dichotomy, which shows up time and time again when these types of surveys are
Access to services is one of the things we are very interested in monitoring;
this slide shows the difference in access to physician services between the
1950s and the 1990s by income group. Back in the 1950s, the higher your income,
the more likely you were to have physician services; whereas in current times,
your access to physician services is the same, whether you are low income or
What has happened with all these bed cuts? As I have said, 25 per cent fewer
beds are available. Day surgery has doubled. The attempts that have been made to
measure the health impact of this have been quite surprising to us. They are
documented in the report, which shows that in Saskatchewan, where some 32 rural
hospitals were closed, the overall health status measures actually improved more
rapidly in the communities where those small hospitals were closed. In Winnipeg,
where this issue was studied, some 15 per cent of hospital beds were reduced. In
fact, the overall health status measures continued to improve as well. That was
a bit of a surprise in this study.
Senator Cohen: Why did that phenomenon happen?
Dr. Millar: There is a variety of possible reasons, but nobody knows
precisely the reason. One possible explanation is that, if there was a small
hospital available and there was major trauma, for example, the trauma went to
that hospital where there were physicians and nurses who were not used to
dealing with that level of trauma. As a result, there may have been delays in
getting to the level of care needed. People are now going directly to a higher
level and better qualified service.
Another of the major problems that the report shows -- and everyone knows it
is true -- is that there has been emergency room congestion. This slide shows
that that emergency room congestion is reflected by headlines. Those headlines
from right across the country have tended to occur in December, January and
February. It has been well shown in more detailed studies that that is connected
to the annual flu epidemic. Much of the congestion, both in the emergency rooms
and in hospital beds in that period of time is driven by respiratory disease and
can be attributed to flu.
What has been shown in some more detailed study across the country is that,
where there is good information on the reasons for that kind of congestion,
programs have been put into place that have dealt with it. As the chair of the
CIHI board is fond of saying, "You cannot manage what you cannot measure,
but where you do have good measurement you can manage it."
In Winnipeg, they brought in a program under which they increased flu
immunization. They made the admissions and the discharges more efficient. They
provided more bed availability during the peak season for flu. They provided
more beds in the communities so that they could move bed blockers out of the
hospitals. As a consequence of that intervention, they were able to avert the
emergency room congestion that was experienced by many centres, such as Toronto,
in the past winter.
What is going on with providers? It is not surprising that there is a lot of
stress in the system, in particular among nurses where there is very good data
now that shows that, amongst all the workforce categories, nurses are suffering
more time off, more disability, more back pain, and so on. The nursing
profession is clearly suffering. Nurses are also getting older.
The same thing applies to physicians. It is very much an older population,
and the number of physicians has been declining slightly.
We are very interested in prevention and outcomes. In terms of some
preventive measures, some data in here looks at mammography, for example, and
early detection of breast cancer. It shows that there are quite considerable
differences by province in the achievements being made there. Similarly, in
immunization, although we believe one of the big areas that we do not have good
data on in the country is immunization rates, we do have good data on
communicable disease rates, and it is a goods news story there. We have been
able to eliminate smallpox and polio and almost eliminate measles, and there is
good news around immunization. However, there are many ongoing challenges in
getting good data and trying to bring everyone up to the same level of high
In terms of appropriateness of care, we have taken a look at the caesarean
section rate across the country. The WHO recommends a caesarean section rate
between 10 and 15 per cent. The overall rate in Canada has been climbing over
the last few years. There was an attempt through the Society of Obstetricians
and Gynaecologists of Canada to reduce the rate, and it went down for a while.
However, it is back on the rise again. In some jurisdictions, they do extremely
well. There are jurisdictions in Quebec, for example, where the caesarean
section rate is as low as 13 per cent. There are jurisdictions on the West Coast
that are up in the 25 or 27 per cent range. There is a huge variability. We do
not have a full explanation for that at this time.
Senator Carstairs: Do you have statistics based on the time of day at which
the C-sections are done?
Dr. Millar: No. It is not recorded in our database as to what time they are
The Chairman: Why did you ask that?
Senator Carstairs: Anecdotal experience would tell that you C-sections are
done so that doctors can get a good night's sleep. They are not done between
midnight and eight. They tend to be done up to midnight. If the labour is going
to progress longer through the period of time, the C-section is done.
Dr. Millar: Our intent here in providing this data is to have that type of
analysis done by the managers and providers at a local level so that, when they
do have very high rates, they can identify exactly that kind of issue. We also
know that in some areas it is driven by women's preferences. Some women prefer
to have caesarean sections. There is a variety of explanations there.
In terms of outcomes, there is a recurrent theme in this report about the
things we do not know. Again, it comes as a surprise to many people when they
realize that we cannot report on good outcome data for many procedures that are
done. Where we do have those data, we have presented it.
We do have an organ replacement registry that is operated by CIHI. From that,
we have been able to show that the survival rates for kidney, heart and liver
transplants are comparable across the country. There is good performance right
across the country and good performance by comparison internationally. It is
similar with communicable disease control and with rehabilitation outcomes. We
do have some outcomes in those areas. It comes as a major surprise to many
people that, for example, the leading cause of deaths is, as I am sure Dr. Keon
has made known to you and to others, heart disease.
We cannot report on outcomes for acute myocardial infarction, how many people
live and die, in a standardized way across the country. We simply do not have
that data. We cannot report on how well people do with cancer or for major
trauma or diabetes or for many of the common disease entities. We simply do not
have, at the moment, any routine outcome reporting ability. We are working on
that, and I am confident that in the course of the next few years for which we
have the funding, we will be able to begin to fill in some of those blanks.
There are many other questions that we cannot answer. We do not have very
good expenditure data at a regional level or by sector. As I have mentioned, we
do not have good information on outcomes. We do not have good wait list data.
One of the hottest political issues is how long people are waiting for
procedures. There is no standardized way of reporting that. Safety is another
major concern of the public: when people go into hospital, will they get the
right treatment at the right time? That is an area that we regard as a high
priority, and we are developing ways to attempt to measure that.
Mr. Chairman, I will stop there and attempt to answer any questions you may
The Chairman: Thank you. May I ask you some procedural questions?
Procedurally, do you intend to produce an annual report?
Dr. Millar: Yes, we are committed to producing an annual report. It will not
necessarily be as biblical as this. We will certainly have not only an annual
report but also a series of reports coming out through the course of the year
reporting on various aspects of the health care system.
The Chairman: We should make sure that when those come out, they go to all
members of the committee. On your list of unanswered questions, I picked the
"waiting line" as an example where you say there are no data. Are you
in the process of putting in place an information system that will get that
Dr. Millar: Yes, we are. We already have in place a system that will be able
to provide standardized information on emergency room wait times. That is in
place, and we expect to have data flowing there within the next year. When it
comes to waits for heart transplants or cardiac care or cancer treatments or
cataracts or hip replacements, those are more difficult, but we are attempting
to work with various professional groups to get those kinds of wait times as
The Chairman: Do you hope to be able to get that information in the next year
or so, or is that some distance off?
Dr. Millar: I would hope to have some of those in the next year or so, but it
is a struggle. It is not easy to do.
The Chairman: To the layperson, it sounds like it ought to be a no-brainer.
Dr. Millar: It is very difficult. You can read in the report quite a detailed
explanation of all the issues around something as straightforward as trying to
figure out how long you have to wait to get coronary artery bypass surgery or an
angioplasty intervention. You need to define that, first of all. When do you
start measuring? Is it when you get your chest pain? Is it when you first see
the doctor or a specialist? Do you start it when you first get your
catheterization? How do you track all those things? We do not have any databases
starting as early as when someone sees the personal physician. The databases in
primary care are absolutely and utterly dreadful in this country -- as they are
in every other country. Bad as it may seem, and despite the amount that we do
not know in Canada, we are still ahead of the pack. It is not as if anyone else
is doing it a lot better. Australia is doing it better, but it is about the only
country that is clearly ahead of us.
The Chairman: We are ahead of the pack because we are a single-payer system.
Dr. Millar: That helps a lot. As well, we do have some big databases. So far,
issues like Bill C-6 have not limited the ability to share that data.
The Chairman: We have been through that in this committee, as you know. I
should say to senators that all of the overheads that the witness used are in
the report, along with a wide variety of others.
We have heard statements that would say roughly the following: Of the amount
of health care services provided to an individual, some 30 or 40 or 50 per cent
is provided in the last six to twelve months of an individual's life. In other
words, the cost of medical care that an individual receives goes up enormously
as the individual nears the end of his life. Is there any hard data that gives a
number to that?
Dr. Millar: How much is consumed by people over a certain age?
The Chairman: No. Let me tell you where I am headed. People have said that
the aging population is one of the big drivers of cost. My question is whether
it is the aging of the population or simply the fact that as you increase life
expectancy the costs associated with trying to delay death as long as possible
in fact inevitably occur at an older age.
In other words, does a healthy 70-year-old put any more drain on the system
than a healthy 50-year-old? Conversely, if a 55-year-old has cancer and is
dying, is there any reason why the cost of that treatment should be less than
the cost of treating a 75-year-old?
Dr. Millar: I would like to rephrase the question in the way I think about
it. Clearly, we are living longer. The corollary to that is: Are we living
healthier or less healthier? If we are living more healthily, then we could
anticipate that the costs would not necessarily go up as we age. The early
demographic findings published fairly recently by Statistics Canada indicate
that we are living both longer and more healthily. Therefore, the anticipated
impact on the health care system is not necessarily as severe as we once thought
it might be.
The Chairman: To get back to my first question, we have heard from some
witnesses whose basic thesis is that as someone gets really sick and ultimately
dies at the end of that process, they consume a very large amount of medical
services in dollar terms in an attempt to delay the end. Do we have any measure
of what that costs? I am asking that because it seems to me that, if it is
correct that that is a disproportionate amount of the medical services one
consumes in a lifetime, then it may be that more than demographics is actually
driving the change. That is to say just because people live longer then, by
definition, they do not die until a later age. We seem to be focusing entirely
on the age of 65, or on the number, rather than the fact that it is simply a
reality that always through life, whenever it is time to die, it is that last
six months that is really very expensive.
Dr. Millar: I am not aware that anyone has done the projections that we would
need to come up with a valid answer. Projecting is a tricky game. Generally, we
have avoided putting a lot of effort there.
The Chairman: Is it your feeling, therefore, that some of the bold statements
of fact on that issue that we have received should be looked at with some
Dr. Millar: Yes. I certainly would.
Senator Carstairs: In looking at what you have provided I have come across
two or three charts in which data for Manitoba was not available. Since that is
my province, can you tell what the explanation is for that?
Dr. Millar: Could you refer me to a specific chart, senator?
Senator Carstairs: I am sorry, but I cannot.
Dr. Millar: Manitoba is featured quite positively in this report because of
the Manitoba Centre on Health Policy and Evaluation, which does superb work and
which has provided a great deal of good data.
The Chairman: There is a chart on page 43 headed, "How Babies Are
Born." There are only eight provinces listed. You do not have Quebec or
Senator Carstairs: It states that Manitoba data are not available.
Dr. Millar: The reason for that is that Manitoba and Quebec do not
participate in one of our databases, which is the discharge abstract database.
The Chairman: Why not?
Dr. Millar: Because they have their own wonderful system, they do not really
need us. They have high quality data. However, there has never been a sharing
agreement set up so that we can capture it. It represents higher quality rather
than less quality.
Senator Carstairs: That is the point I wish to make. If we are to reform the
system, then we have to be willing to share all our information with one
another. The fact that they are not included in this -- and I knew they had
better information, as a matter of fact -- disturbs me because there does not
seem to be the desire to share.
Dr. Millar: We would welcome any interventions in that area.
Senator Carstairs: I will do what I can. The second last slide is a glimpse
inside the system. It has to do with rehabilitation outcomes. I was quite
surprised by what I saw. It seemed to me that the improvement in functional
status under joint replacement was very small. Yet, we hear constantly, from the
elderly in particular, about the constant need of joint replacement.
Dr. Millar: It is an interesting observation. You will notice that this is
under rehabilitation services. There are many things you can do for someone who
has had a spinal injury and, over the course of time, see big improvements. For
someone with an amputation, there is not much that you can do over time. I
suppose that is a reflection of the degree to which you can expect to see
change. This does not tell you what the expected change is. It just tells you
what was achieved. These data were drawn from a pilot study that is beginning to
explore the types of outcomes in the area of rehabilitation. It is like an early
Senator Keon: I am really pleased to see the first report, which I think is a
great beginning. Do you happen to have the flu data province by province? I
think there is something very interesting falling out there, at least
anecdotally. For example, Alberta boasts that the flu wave hardly affected them
because of their regional organization and so forth. Ontario was hit the hardest
because there is no regionalization. Do you happen to have graphs for each
Dr. Millar: They are available, but we do not have them in that format. They
could be looked at, but I have not seen them in that way. They come from LCDC at
Senator Keon: It would be interesting to get them out before next year's
epidemic, because this is one loop where we could have feedback almost
Dr. Millar: Indeed.
Senator Keon: Senator Carstairs referred to the end of your report and the
short rehab section that continues on to home care. As the report indicates,
this is just a beginning. I have felt for a long time that this is one of the
areas that have to be addressed and organized.
Do you have in place a mechanism for looking at other countries that have
invested a lot in this area? I am thinking in particular of Germany. About 20
years ago, they invested a great deal of money in rehab centres, which they
built all over the country. They then found that they had a dysfunctional
program from which they could not withdraw people and so forth. In your report
you present continuity in terms of home care and rehab, which is terrific. What
template are you trying to develop to look at this?
Dr. Millar: When developing indicators, wherever we can we are doing it to
conform with international standards, if there are any. It is very easy for
things like life expectancy, where there are some standard methodologies. The
fact is that for many of these things we are the cutting edge. We are ahead of
most other countries, so there are no comparative data. We are just inventing
them on our own and hoping others will follow our lead. In fact, that is the
strategy we are taking within the country. For example, the cardiac care network
in Ontario has set a standard. We are encouraging that to be picked up in other
parts of the country.
Senator Keon: How are your links unfolding with provinces like Manitoba and
ISIS in Ontario? Are you getting direct links from there or is your information
coming in through periodic reports or information-gathering sessions?
Dr. Millar: For most provinces, the links are very direct and they
participate fully. We operate 14 databases for expenditures, organ replacement,
major trauma, et cetera. There is a number of them. In most of those there is
full provincial participation. There is this exception of Manitoba and Quebec
for the biggest database, which is the discharge abstract database. By and
large, there is very good cooperation with the provinces.
With specific organizations like ISIS, we also have a good working
relationship. ISIS draws on our data for many of the research projects they do.
Having said that, we are certainly looking for opportunities to develop further
partnerships with whoever is interested in better using these data that we hold.
Senator Fairbairn: This looks like a very interesting publication. I am sure
many questions were asked by you in terms of building this mechanism to get
I am particularly focused on the final part about home care and institutional
care. I did notice the headline that everything old is new again with home care
in Canada. This is one issue of the new health care system or the new health
care reality in Canada that we need to know much more about -- not only where it
exists but how it works. I guess it exists in every province of Canada. How it
is connected to the hospital and the physician is one of the big questions,
because sometimes those connections are very shaky, although the program in
theory may be good. At this point in time, are you able to make any comparative
comments between provinces in Canada, or are you still at the point where you
are trying to get that kind of information? Is that information available right
Dr. Millar: At the provincial level, you could get comparative data on
expenditures on home care and long-term care, but if you want to look at any
sort of performance measure, there are none. The good news is that one of the
many projects that we have underway is to develop better expenditure data at the
regional level so that we can start to get a handle on how much money is going
into all the various sectors, including home care and long-term care. Another
project is looking at continuity of care indicators. That is one dimension of
performance across the system that we are trying to develop, and we are working
together with the Canadian Health Services Research Foundation to get some
continuity of care indicators. In addition to that, there is a specific project
looking at performance indicators in home care and long-term care. In the
continuing care side of this, there already are data standards. A private
company has developed a minimum data set, and that is now being picked up across
the country. We are sort of the mediators for that. That is coming on stream
On the continuing care, the institutional side, I am optimistic that we will
have good data that will provide us information on performance on the
institutional side of community care. On the home care side, within the scope of
the projects we currently are running, we may not have the data, but we will
have developed the indicators and the data definitions and can begin the process
of having them taken up by the provinces.
Senator Fairbairn: I am sure that we all in this room have had experiences of
one kind or another in respect of home care. I have had two -- one in Alberta
and one here in Ottawa. It struck me that it would be very useful were
information available. Some of the gaps in both of those provinces were in
totally different areas. People could learn from other people's strengths and
weaknesses. Already we are hearing in the study that we have just started that
this whole broader definition now of health care being in the home and the
community is probably one of our greatest challenges.
Dr. Millar: I agree. It is a major challenge to find the performance, and you
must also ask whether someone is being well-helped to move through that system
Senator Fairbairn: To find their way through.
Dr. Millar: Yes.
Senator Gill: You said that your Institute had two major objectives: the
report on the health of Canadians, and evaluating the performance system. How
can your recommendations be implemented? You referred to the standardization of
services, in comparison with other countries and among the regions of Canada.
How could your recommendations be implemented across the country? Once the
recommendations are made at the national level, how do you take geography into
account? How and where can your recommendations be implemented?
Dr. Millar: Our organization is not mandated to make policy recommendations.
Our mandate is to provide the very best possible information to put into the
hands of policymakers so that they can use the information to develop policy.
Our task is to get the best information, but not to make policy recommendations.
How do we envision the data being used to be relevant both internationally
and between regions? We envision that the data is being provided to the
governors of the system -- ministries of health, regional health authorities and
so forth -- and also to the provider groups and the managers in the system, and
also directly to the public. We are targeting this data at several difference
parts of society.
For the managers and governors in the system, the intent is to support the
development of better policies. For the health care system providers, this is
clearly intended to support improved quality of service, the continuous quality
improvement of service. A very practical example of that would be the C-section
rate. For example, the C-section rate in Victoria, B.C., is 24 per cent. That
has already stimulated people to pay more attention. They would go to one of the
jurisdictions in Saskatchewan or Quebec that is down around 13 or 15 per cent
and say to them, "Well, how did you do it? How did you get your rate cut in
half like that?" It is to provide that ability to improve quality. Then, by
getting this data into the hands of the public directly, we believe that with a
better informed public you get, in fact, better governance, ultimately, and
better accountability for what the public is getting for its money.
Those are the ways in which we are disseminating this information into
various sectors to have its impact, but, again, not making direct policy
Senator Gill: Do you have any data about Aboriginals and, if so, how did you
get it? Who do you deal with at the national level?
Dr. Millar: The question of aboriginal health is very difficult. We do have
data on health status, how healthy they are, and we know they are much worse
off, although the gap between aboriginal and non-aboriginal is improving. There
are generally improvements in both sectors. There still continues to be a huge
gap, and it is the most egregious gap in the country. Aside from that, we have
very little data. For example, when First Nations people go into hospital, their
status is not recorded on the data, so we have no way of tracking that. We do
not have any routine way of discovering what level of services they are getting
or the outcomes related to that service. Any data available is mostly done on
the basis of surveys. There have been some recent aboriginal health surveys. The
best available information is in some Health Canada publications that have
recently come out. If you refer to those, I think you will find that that is as
good as it gets. We have very little in our database that can help shed light on
That being said, there is one area where we can help. Although we cannot
identify specific aboriginal people within communities, there are communities in
the country where they are largely aboriginal folk: Northwest Territories,
Yukon, Nunavut, northern areas of Manitoba and so forth, Saskatchewan, B.C. and
We can do small numbers analyses in those areas and provide the same type of
data by region, as you see in the back of the document, and then go down to
smaller regions. We can provide this type of array of data, which gives some
sense, then, of how those largely aboriginal communities are being served and
the outcomes related thereto. That is an area on which we are moving ahead.
The point I am making is that that will not be specifically aboriginal; nor
will it be able to split out Métis from Innu or Haida.
Senator Fairbairn: Would it be the case, then, that in any given hospital you
would not have a picture of the clientele of that hospital, whether it be
aboriginal or people from other backgrounds? In other words, is there any way in
which we can define that hospital population?
Dr. Millar: There is only one database that we have in which ethnic
information is entered. That is the Canadian Organ Replacement Register. That
captures, for example, aboriginals, Vietnamese or whatever you want. Aside from
that one database, hospital databases do not record that. That has been at the
wish of the ethnic groups themselves, who do not want to be identified.
The Chairman: You said earlier that, overall, lower-income people have a
lower quality of health. You also said that lower educated people and rural
people have lower quality of health. We recognize that the vast majority of
aboriginal people in your database would be low income and rural. Therefore,
even if they were not aboriginal, they would not have as good a health record as
the average Canadian. Can you adjust your data to understand how much, beyond
the fact that they are low income and rural, owes to the fact that they are
aboriginal? In other words, I am trying to understand if you can isolate the
aboriginal parameter alone or if the aboriginal data is in part because they are
aboriginal and in part because they are low income and rural?
Dr. Millar: I can answer that question from the literature in broad terms. We
know that racial or genetic factors on a population basis have a very small
amount of explanatory power in explaining these differences. The Japanese are
the healthiest people in the world and have been for 25 years, in terms of life
expectancy. However, when Japanese move to another country, like Hawaii or
California, then, by and large, they take on the same mortality patterns as the
country in which they live. The aboriginal data all point the same way. This is
not a question of being aboriginal. It is a question of having low income, low
education, low employment and systematic exclusion from opportunity.
The Chairman: What about the fact that they live in rural areas?
Dr. Millar: The same thing applies in downtown Toronto or downtown Vancouver.
The Chairman: The data one talks about is aboriginal data because for various
public policy reasons Canada has a different responsibility for aboriginal
health. In fact, it is really a commentary on education, on income and a variety
of other things for which we happen to have one particularly identifiable
subgroup. Is that fair?
Dr. Millar: I absolutely agree with that.
The Chairman: I thought that would provoke a rebuttal from Senator Gill.
Senator Gill: How do you explain the huge increase in diabetes among
aboriginal people? If it is not cultural, how do you explain it?
Dr. Millar: There are wrinkles in this story. I said that there are some
small explanatory powers. It is not as if it does not have any. The first time I
discovered this was when I was a medical officer in Prince George, B.C. I
arrived on the job and found that they had a 50 per cent higher death rate.
Immediately, when that hit the papers, everyone thought it was because of the
pulp mills or that they drank too much. In fact, what we found is that they die
more of heart disease, of cancer, of respiratory disease, of diabetes, of
suicide, of homicide, of motor vehicle accidents -- more of everything. The
pattern that has been shown time and time again is that, where you have a
population of people dying more, they are dying more of everything. That is
because they are simply more susceptible to getting sick and dying from whatever
happens to be around. It is not to say that genetics is totally irrelevant. It
does come into play. However, the powerful drivers are those things that make
people more susceptible to disease. Those are related more to income, education,
jobs, early childhood care, community cohesiveness, and so forth.
Senator Cohen: I have a question about immunization in Winnipeg and the
successful results of cutting down emergency room delays. How is that
information disseminated across the country, for example, to New Brunswick? The
answer may be similar to the C-section answer. Is this report the first issue?
Dr. Millar: Yes. The Manitoba Centre for Health Policy and Evaluation
routinely produces reports as well. The underlying information that led to the
policy developments in Winnipeg had already been published. It does not get huge
media attention. This is an attempt to add to the dissemination of that type of
Senator Cohen: Wouldn't a simple solution be to immunize the people, and thus
have less of a back up?
When Dr. Fraser Mustard visited us a few months ago, he said that a lot of
the diseases of old can be traced back to the first five or six years of a
person's life. Have you done any studies on that in conjunction with this
report? Where did he get his statistics? It seems that we are very advanced in
our medical knowledge, but in our information gathering and data we are almost
Dr. Millar: You have to understand that this report is an attempt to get
standardized comparable data in every region across the country. That is a far
different thing. Dr. Mustard's work is all based on research studies -- small,
intense gatherings of data for a very specific academic purpose.
Senator Cohen: That could impact on health.
Dr. Millar: That is right. To answer your question whether we are doing
anything in this area, we certainly are. CIHI received $95 million from the
federal government a year ago, February, for three major projects. One of those,
which will account for $20 million, is the Canadian Population Health
Initiative. That is doing further research work in particular in the area of
population health. One of the areas that will be researched is that early
One thing I should mention is the fact that at the moment, amongst all the
indicators that we are trying to track in here, we do not have one for early
childhood. We cannot say how well children are doing, region by region in the
country. There has been an indicator developed at McMaster. It has been piloted
now. One of the places in which it was piloted was Winnipeg. It is showing some
results. Fraser Mustard has been part of that as well.
We are working with HRDC, McMaster, Statistics Canada and the Conference of
Ministers of Education across the country to see if we cannot get that in place.
It is used when children hit kindergarten. It can be done by the kindergarten
teacher. It is not used as an individual way of identifying problem children. It
surveys the whole class of kindergarten kids and captures how well they are
doing in their ability to read and recognize words, and it tracks their numbers
abilities, their social behaviours, their classroom behaviours and their
It captures an array of about five or six dimensions and gives you a snapshot
of how well the kids are doing at a given community. It relates that to the
availability of things like qualified day care and various things. There is a
community mapping piece that goes with it. It is very cost effective. We could
assess every child in the country for as little as $4 million. This is something
that we are trying to actively get in place as quickly as we can so that we can
capture that very important dimension.
Senator Cohen: This would also give us a snapshot of the low-income
population and what the results can be when you do not have access to healthy
eating and life-style. That sounds interesting. It will be very informative for
those of us who are not in that profession, such as myself.
The Chairman: Dr. Miller, your last answer says to me that there is a lot to
be said for putting much more money in prevention rather than cure, and
prevention starting at a very young age. Is that a reasonable conclusion?
Dr. Millar: It is, certainly in the area of early childhood. The data has
been well examined, and repeatedly examined. The business case on this is very
solid. The number that springs to mind is that every dollar invested in good
early childhood care saves about $7 in the public sector over the subsequent 20
years. It saves in terms of health care costs, justice system costs, and so
Senator Fairbairn: I am very glad that you gave us a vehicle to get that
answer. I was going to ask how, if at all, you were able to factor a literacy
component into any of your statistics.
What you have said on the early childhood side is critical. This committee
has already heard one of our presenters comment on the other end of the scale,
which of course can show you how the cost escalates. With our senior citizens,
we can have up to 65 per cent having difficulty, for a variety of reasons,
including skills, being able to read and understand prescriptions and medical
advice. Anecdotally, the Canadian Public Health Association is considering this
a distinctive enough problem that they are devoting their national meeting this
year, a few weeks from now here in Ottawa, to how literacy levels affect every
level in our society.
The early childhood effort will give us a tremendous benefit and is much
easier to do than when you get up into other age groups. Do you suppose there is
a way that you can find mechanisms to measure against literacy skills, against
learning skills, in adults?
Dr. Millar: Literacy is a tricky area, and I am not an expert in literacy
measures. You probably know that, if you look at international comparisons, it
says that 98 per cent of Canadians are literate, or 99 per cent -- a huge
number, but we know that that is not addressing the issue of functional
Senator Fairbairn: Then over 40 per cent have problems.
Dr. Millar: To get data on that by region requires surveys that are quite
labour-intensive to administer, I understand. The other major endeavour, as part
of this present project, is with Statistics Canada. They have $40 million of the
$95 million. A good deal of that money is going into the Canadian community
health survey. That will capture many things of interest, like smoking rates and
diet and obesity and physical activity, but it will not capture literacy because
of the difficulties of capturing that in a short survey instrument. It remains
problematic. I am personally not aware of anything on the horizon that will do
that in a systematic comparable way across the country, but I may not know about
everything that is going on.
Senator Fairbairn: Starting at the beginning is the best way that we can
solve the problem.
Dr. Millar: We could get it at least at the kindergarten level, which I agree
is a perfectly reasonable place to start.
The Chairman: Going back to your opening slide, you talked about Canadians
spending less than some other countries per capita and nevertheless being
healthier. Is it a reasonable conclusion from that, and from some of the other
data in the CIHI report, that it is difficult to draw a direct correlation
between increased funding for health care and the increased health of Canadians?
I ask that because federal and provincial governments of all stripes get huge
publicity by announcing an extra billion or million or whatever for health care.
I think the average citizen reading that headline says that is a good thing
because the health care system will be better and therefore Canadians will be
healthier. Your data leads me to suggest that that conclusion is not obvious. It
is certainly not obvious that, if you put $2 billion more in, you would get
twice as much improvement as if you were to put $1 billion in. Is that true?
Dr. Millar: It is true to say it is complex. You must be careful to define
what it is you hope to achieve. I think that is the key here. It probably would
not change much in terms of life expectancy, because we are already at a very
high level of that. Dumping more money into the system is not really meant to do
that. We are really meant to be providing services that people need to achieve
better health measured by other means than life expectancy. If people are
getting a hip replacement and they are pain free and can function better, then
they are healthier, but we do not capture that by life expectancy. I think a
large part of the drive for more funding is to provide better services that do
in fact often make people healthier.
The Chairman: Better and faster.
Dr. Millar: Yes. The flip side of this is the point I made earlier about why
it is such a political issue and why it is so important that it be addressed
politically. The more money that goes into the health care sector, and as you
know that is now up to 40 per cent of some provincial government budgets, the
less that is available for other things like early childhood care. There is
always that balance that one has to trade off, and that is very important.
The Chairman: In light of what you said in response to Senator Cohen,
investment not in health care but in something else may in fact in the long run
have a bigger impact on health care than the direct investment in health care.
Dr. Millar: Precisely.
The Chairman: Thank you for attending today. Will you please tell your
colleagues at CIHI that, as they get various reports, not only would we want
them circulated to the committee, but as long as we are in the process of doing
this study we would like them to come to the committee and take us through them?
Dr. Millar: Certainly.
The Chairman: Senators, our next two witnesses are Professor Margaret
Somerville from McGill and Professor Laura Shanner from the University of
Welcome, and please proceed.
Ms Margaret Somerville, Professor, McGill University: Thank you, senator. I
have submitted two papers to the committee. One is an article entitled,
"The ethics and law of access to new cancer treatments," which deals
with the access issues at an individual level. I have also submitted a draft of
a chapter -- and I will do a bit of advertising here -- from a forthcoming book
that I have called, The Ethical Canary. There are two chapters in that on health
care allocation, access, and ethics resources issues.
I would now like to make a few pointed remarks.
The first point to make -- and it is one that Professor Shanner will expand
on -- is that ethics is not simply a matter of good conscience. That is
essential, and we have to make sure we have it, but it is much more than that.
It is a structured analysis in which we look for the values, and when we have
conflicting values, we try to justify the choices we make. That is really what
we have to do in limiting health care resources ethically. We have a situation
of enormous complexity, and, unfortunately, enormous, unavoidable conflict. I
want to speak at an even larger level than the previous witness, than just the
health care system itself. I want to speak at the societal level, because in
what we can call post-modern, secular, pluralistic, multicultural, western
democracies -- all adjectives that apply to Canada -- we think that health care
is the most important societal institution in value carrying, formation, and
promotion -- and, if it does not do those things well, value destruction -- for
There are many reasons why we have great difficulties in dealing with
medicare, but I should like to discuss one in particular. I think Canada is
probably the strongest example in the world of this. I come from Australia, so I
am relatively familiar with their system, which is not dissimilar to ours, but
the fact that Canada has always placed such a strong emphasis on a publicly
administered, egalitarian system, and that there has been largely, to put it at
its mildest, an inhibition of private health care, makes it even more important
in terms of those values or functions at the societal level as a whole.
Therefore, whatever we do, we are not just thinking about, does some person or
some population get better health care? We are really thinking about, when we
make those decisions, what are we doing at that values level?
Health care is so important because, whereas in the past, most of our
communities created what you can call their "cultural-societal
paradigm," which is really just a shared story that we all buy into, mainly
through religion, in our kinds of societies, we have to create it through a
secular institution. We usually create it through an institution that carries a
value of caring for each other, because caring for each other is actually the
existential glue that holds us together as a society. An institution that can
carry the value of caring for the whole society can equally carry the value of
not caring, if what we do is either not care or even just appear not to care. I
think some of the outrage that we are seeing in Canada -- and I get lots of
calls in my office -- is because suddenly people feel that they are not cared
for any more or that there is not an appropriate level of that value of caring.
Therefore, when we make these decisions, we have to keep those other,
metaphysical aims and possible damages in mind.
The other interesting thing about this situation is that every one of us in
Canada is in a conflict of interest, and the reason is as follows. As a
taxpayer, I do not want to pay more tax; in fact, I would like to put in a
strong plea that I might be allowed to pay less at some point. On the other
hand, when I am sick and I go to the Royal Victoria Hospital, I do not want
someone to tell me they cannot afford to treat me, or that I have to wait six
months for something that should be done now, or that I have to be sent to the
United States for radiotherapy treatment or whatever it might happen to be. We
have this ambivalence inside ourselves: Yes, we want health care to be right,
especially when it is for us or those we love; and no, we do not want to pay any
Another problem is that part of our societal vision of health care has been
founded on the myth that we did everything possible, in terms of health care,
for everyone who needed it. Our new information age has absolutely shattered
that myth. I think that is only going to become more true.
I see the challenge as how to keep those features of the system that we need,
not just for practical health care on the ground but as a Canadian society, and
at the same time face the reality that we cannot do everything for everyone that
would be of benefit for them, in terms of health care.
It is an incredibly difficult challenge to work out how to do that. I think
we have been doing it on a piecemeal basis, we have been doing it according to
what hits the front pages of the National Post or The Globe and Mail, and we do
not have a coherent approach.
I think there are a multitude of suggestions that we could make, but I can
only mention one or two of them. One is that we know that our society is no
longer based on what is called "blind trust", which says, "Trust
me, because I know what is best for you and will look after you." That is a
paternalistic system. We see that very forcefully in the area of medicine in
particular. With the requirements of the doctrine of informed consent, which
Professor Shanner is going to talk about, we have changed to what is called
"earned trust." That says, "Trust me, because I will show that
you can trust me, and you only need continue to trust me while I continue to
earn your trust." Blind trust, by contrast, is based on power, status, and
authority. You will not have trust present if it is based on earned trust and
you are not earning it. Again, I think there are problems in the health care
system right at the governmental level. I would suggest to you that a lot of
Canadians are not sure that their trust is being earned at the level of whether
health care will be provided for them and those they love when they need it.
In that respect, I think you need to do some very particular soul-searching
as politicians. I think I can call you politicians in the Senate, although in
some ways perhaps you are not. One of the most unpopular suggestions I have made
to politicians is implicit in the question of whether it would be ethically
required of you, as the decision makers about what will constitute our Canadian
health care system, to be absolutely subject, as any ordinary citizen would be,
to the basic access to that system? In other words, do you, when you are older
and influential, politically well connected, socio-economically well-off, get a
transplant if someone who is just an ordinary, average Canadian, would not? This
is a very difficult question, but I think it has to be faced.
One way to look at health care is to see it as a lifeboat, and realistically,
that is what it is. No matter how much we talk about putting money into early
childhood care, which I think is ethically required and good, ultimately, we
still face maximum health care costs for people when they are older and
chronically ill and, later on, dying.
The only difference is that we face them at 80 or 90 years of age instead of
at 50 or 60 or 70. We still face them, unless people simply drop dead, which is
becoming less likely with our new health care. There is now more that we can do,
that we can afford to do, and the real ethical challenge is to work out how we
can make those choices without being unethical either in the health care system
or in the larger society.
I would also point out that we have grossly underdeveloped organizational or
institutional health care ethics at the moment. We have fairly well developed
clinical ethics. That is important, because the ethics can differ at the
different levels. There are essentially four levels: The micro or individual;
the meso or institutional; the macro or societal or governmental; and we have
added to that recently the mega, which is the global level, which can also
indeed influence our health care. In fact, one of the things most influencing
Canadians' claims for very high-tech, high-level health care currently is they
are going on the Internet and seeing what is available, particularly in the
One of my colleagues who is a physician phoned me the other day to say he
does not know what to do because he is absolutely beside himself about lack of
time. He has people coming into his office who have received a diagnosis, who
have gone on the Internet, who have 200 pages of print-out, and they sit down
and they say, "Doctor, I would like to start here and discuss this with
you." He phoned me to say that he was telling them, "Look, I have 20
minutes to see you. We can do one of two things. We can either talk about what
you found on the Internet, or I can examine you and see how well you are doing
and prescribe what you need, but I do not have time to do both."
We are fuelling people's claims at the very time that we cannot provide for
them. This has been referred to as "the cost of our success." If we
had failed, we would not be here today because there would not be anything we
would have to worry about being able to pay for or not. It is because our
medical research been so incredibly successful, especially in the last 15 years,
that we have those dilemmas. They will not go away. They will increase. We need
structures within which we can make these decisions.
To conclude, we are in a bind because we have two conflicting aims with
medicare. There is the very practical aim of providing health care on the ground
at a reasonable level with reasonable access to all Canadians who need it. At
the same time, medicare carries a vision of our Canadian society and its values.
It must operate on both those levels. What might be reasonable for one of those
functions may not be for the other.
After thinking about this and writing it down, I came to the conclusion that
if we want it to continue to function as a very important, value-creating
mechanism, probably we have to give the most attention to what we need to do in
practice in providing health care. No matter what we say, if we do not do that,
people will not find the values that they need in our health care system. We
should keep in mind it is often said that the ethical tone of a society is best
tested by how it treats its weakest, most in need, most vulnerable members. For
most of us, the only time we experience that is when we are sick. It is very
The Chairman: Thank you. I will ask Professor Shanner to make her comments.
Ms Laura Shanner, Professor, University of Alberta: Thank you very much for
inviting us here today. I will confine myself to some very scattered remarks to
which you can refer later. I have previously made available a copy of an
extended outline with this set of titles. It cannot possibly be read in 10
minutes, so I will not even try, but I will hit some highlights. I have also
included a chapter I wrote for a health law practice manual on theoretical
approaches to health ethics and its relationship to the law.
To start, we might even define ethics. One key element is that it regards
others. Selfishness or self-regard is never considered an ethical principle or
framework. There is, of course, reasonable self-interest insofar as we do not
need to destroy ourselves in an effort to save others. There is a point at which
our interests must be held to be equal with those of others. There may be times
when we must accept sacrifices or compromises because the needs of others are
Universality implies that anything I would expect you to do, I must expect of
myself. Professor Somerville mentioned justification. This is not an attempt to
find good-sounding, ethical words to justify the decision we were planning to
make anyway. It is, instead, a requirement that we go back to the beginning,
decide what we are trying to achieve, what issues are at stake for everyone who
may be affected by this decision, and then to work through not only the most
practical set of outcomes and mechanisms, but also juggle the values and the
interests of everyone involved.
Finally, ethics must always concern itself with matters of the most serious
importance -- of course, our health, our opportunities in life, our degree of
suffering, and the fact that most of our health care interventions arise in
poignant human moments, like the birth of a child or when we confront our own
death or the deaths of loved ones. Health care is inherently infused with
ethical concerns simply because of its nature.
I point out that public policy is also infused at all levels with those same
sorts of concerns. The justification or the point of a policy body is to
coordinate the efforts of all in the community to achieve things that are very
important, and that we simply are unable to achieve working alone. Once again,
the welfare of the community, our opportunities, our overall health status, our
ability to succeed together, are very important to us individually.
Finally, it has been said that you cannot manage what you cannot measure.
From an ethical perspective, I would refer to you Howard Brody, who pointed out
that sometimes the measurable drives out the important. What is important? There
is a very long list of different values that infuse our entire lives, not merely
health care or health policy. However, in both health care and health policy,
the attention to ethical values must be extraordinary, much higher than is
required in our daily lives. I will talk about a few of these in greater detail.
The core of health policy tends to focus on the balancing of individual and
common interests. One way of understanding this is that the protection of those
who are most vulnerable, and respect for persons or individual autonomy, may
very often be in conflict with what is just or fair, or with what is good in
terms of the best outcomes.
I suggest that, as we try to balance these individual and common goods, you
imagine that you are wearing bifocal glasses, of which one lens lets you see up
close. In health care, it would be the patient and the patient's family and
loved ones for whom nothing is more important than relieving the pain, delaying
the death, achieving a healthy birth, and related concerns. At the individual
level, ethics of beneficence and respect for those individuals indicate that we
need to do everything humanly possible that may be helpful.
At the same time, we need to use the other lens, the distance lens, which
allows us to see the entire community. This is where the justice questions, the
allocation and shepherding of resources, and the overall good that we seek to
achieve together must be considered. While individuals must never be subsumed or
"chewed up" in the attempt to promote public or common goods, we do
have to consider that what is best for individuals may not be best, and may even
be harmful, for the collective. We need to somehow look out of both lenses at
the same time without getting dizzy. This is quite a challenge.
As you can see, with multiple values, it will be very difficult to find a
single right answer that achieves everything that needs to be covered. Indeed,
this is not a complete list of relevant ethical values.
We might, therefore, focus on ethics not so much as the outcome of the
specific yes or no answer, but as a matter of process -- how we engage in our
reasoning, what we take into account, whether we are acting in an accountable
and virtuous way. Whether we do in fact care about the results or that our
deliberations occur from a position of genuine compassion for our fellow human
beings, recognizing that every choice will leave something undone. Some of these
may not be as well protected as we need them to be and that may leave what is
called "a moral residue."
Let me discuss a core principle, non-maleficence, which simply means, do not
hurt people. This is the most binding, most minimal limit of ethical behaviour:
Above all else, no matter what else you do, even if you do not actively try to
help someone, for heaven's sake do not leave people less well-off than they were
before. In a clinical context, this would refer to the physical safety of
patients and their medical outcomes, their emotional well-being, and of those
who are related to or care about them, and respect for their personal values and
life situations. There may be things that individuals cannot or will not
sacrifice for other goods. Those values may not be consistent among members of
the health care team and the patients or families, or the policy bodies and the
larger social orientation.
One of the most important problems that we see with Alberta's Bill 11 fits in
here, under clinical best interests. By setting up what has been referred to as
a "non-hospital hospital," the non-hospital, long-stay surgical
centre, we create a real concern for the welfare of patients following surgery.
Why would you need to stay overnight after surgery? It is not so that nurses can
notice if you happen to go into crisis. It is so that someone who is prepared to
help you with whatever sort of post-surgical complication might arise is there
to do so. These non-hospital surgical centres would not have a full staff of
clinical specialists in cardiovascular disease or neurological complications, or
complications with respect to any other body part that might be injured. They
would not be training medical residents. Who exactly is going to be on call at
three o'clock in the morning when the highest-ranking surgeons in an area have
gone home for the day? There are very serious concerns there.
Let me deal with the policy effort to protect and strengthen public goods
rather than undermine them. If we talk about an approach dealing with the whole
health system rather than a piecemeal one, again Bill 11 fails. What good is
there in providing for surgery when the real crunch in the health care system
involves recovery beds, not surgical centres? Again, we have to look at health
promotion and protection, the areas of poverty relief, education, environment,
all of those important things.
My next topic is justice, the fairness of allocation. There are several
different forms of justice. The most important one for health care is social
justice: relative poverty or wealth, access to opportunities, access to health
care. Certainly, it is very clear that those of us who work in allied health
professions know the right people. I can easily get in to see a specialist. I
know the language, I can do the research, and I have connections I can call.
Other people are not as lucky. That disparity in availability of access is a
significant moral issue.
I would also call attention to what have been called the "natural
lottery" and "social lottery." Whatever we may have worked hard
in our lives to earn, we did not earn our parents or our genetic endowment. We
did not earn the society in which we live, whether it is racist and
discriminatory, or one that truly values equal access, equal justice, and
non-discrimination. The fact is that, wherever we start from, which is utterly
beyond our control, may greatly affect our health status and need for health
care and may also set the ground for our ability to acquire resources to access
that care later. That needs to be taken into account when primary goods are at
stake, such as the ability to feel relief from suffering, to engage in education
or employment, to take care of family members. It is not fair to limit access to
health care based upon initial conditions that could not be controlled.
There are several different criteria of distribution. Need, equal access,
and, to some extent, first-come-first-served, are crucial to health care
systems. These other options of merit, equal shares, or by lottery or random
chance, may be helpful in other domains, but not in health care.
It has been observed that the need for health care is literally infinite. We
are mortal creatures, and every time our lives are saved, the one guarantee is
that we will return with another life-threatening complication. Further, as we
take care of the big issues -- my life is not currently threatened -- we become
aware of less compelling ones and seek treatment for them, too. This extends to
medical cures for baldness or toenail fungus, among other things, while other,
more serious health care needs may go unmet.
Informed consent is a foundation of health care, insofar as treatment
administered to a patient without free, voluntary, informed consent is a form of
assault. It is also foundational in health policy. If a team is elected without
the informed population, then people do not know what they have agreed to. If a
decision is made that is not part of the elected mandate, then again there has
been no information and little or no opportunity for consent. This would be an
important concern, in my view, about the process surrounding Bill 11 in Alberta,
since three times now the public has said they do not wish increased
privatization. Nevertheless, as of last night, the government has passed Bill
11, with closure actually used at all three levels -- at first, second and third
reading -- to end debate prematurely.
Disclosure requires the utmost in honesty, first, in providing available
information and admitting what we do not know. Special attention must be paid to
risks. Again, in the Bill 11 context, the risks concerning NAFTA implications of
increasing privatization and overnight stays in for-profit facilities are real.
We need to promote understanding through a genuine dialogue, giving equal
consideration to all available evidence, rather than directing it in a certain
Next is voluntariness. Again, there are concerns with the process in Bill 11.
The manipulation of wording leading us to the non-hospital hospital is an
excellent example. The definitions are placed at the end of the bill rather than
up front, as is typical, so that the actual definition of a private hospital
escapes most people's attention unless they know already what they are looking
Let me talk about external coercion factors. Holding the Tory Party caucus to
a party vote rather than a vote of conscience, or according to constituents'
wishes, is in fact a form of coercion. Again, the rush to push the bill through
despite protests seems to be a coercive factor as well.
Next is the coercive factors of a situation. In health care, we need to
realize that the patient may be vulnerable, frightened, in pain, compromised by
the illness. In politics, we need to understand the limitations of the
communication between the public and the policy makers. Attention has not been
paid to this except to use those constricting factors to the benefit of the
Since there is need for informed consent, and given the difficulties inherent
in truly informed and free consent, we must have a trust relationship of the
highest order in both the health care and policy relationships. This is due to
the disparity in knowledge or power. There is a duty for the more powerful to
not merely avoid trampling on the less powerful, but also to come to their aid,
to protect the most vulnerable. We need to understand our motives and choices
when we are in positions of power, and we must, therefore, avoid even the
appearance of a conflict of interest, let alone an actual one. Violations of
this trust will threaten not only the individuals who might be affected, but
will also threaten to undermine the entire institution of either health care or
the democratic political process.
I have for you a document taken from the New Democratic Party of Alberta Web
site, and the address is on the copy. This outlines the shareholders of the
Health Resources Group, which is now based at the old Grace Hospital in Calgary.
Jim Saunders is the former chief operating officer of the Calgary Regional
Health Authority. The RHAs are supposed to be at arm's-length from the
government in power. However, other Calgary Health Authority members include
Jack Davis, a former secretary to the provincial cabinet, and Jim Dinning, the
former treasurer. There are several members who are involved in a variety of
health care investment firms that have all paid into supporting the Health
Resources Group. This is clearly the motivation for Bill 11.
The initial representation was that Bill 11 would reduce the waiting list for
hip replacements. On the grounds of danger to patients, the college of
physicians and surgeons said that would not be acceptable.
A second attempt was made to justify overnight-stay surgery with
appendectomies, which are not elective but emergency procedures. You would need
a full emergency room and staff for non-appendicitis cases of abdominal pain.
Now they have hit upon hernias, as is done at the Shouldice Hospital in
Ontario. Again, HRG is an orthopedic centre. It looks as if this is a bill
looking for a procedure to justify it rather than a clear response to the needs
of the health care system.
I will stop there. There is much more to be said, both about ethics in policy
and in health care provision, and about Bill 11, but I am open to questions.
The Chairman: Before turning to Senator Keon, I would like to make several
observations, initially to Professor Shanner, about her comments on Bill 11. I
do not want to be taken as a supporter of Bill 11, but I have great difficulty
with some of your conclusions.
You seem to feel that it is unethical for governments to proceed with
legislation to which the public is very opposed.
On that basis, this country would never have abolished capital punishment in
1975. I regard that legislation as one of the more positive things that I have
been involved in in my life. Every poll repeatedly showed that 80 per cent of
the public was adamantly in favour of capital punishment. In fact, I have
difficulty with the premise that it is an ethical issue -- because it clearly is
not -- for governments to do things to which there is massive public opposition.
It seems to me the point of government is to lead. It is very clear that you
do not like the way it is leading, but that is a value judgment that is
difficult to elevate to the level of ethics.
Dr. Shanner: May I respond?
The Chairman: Certainly.
Dr. Shanner: I certainly would not agree with the blanket statement that
governments should never act in ways that are contrary to public opinion. The
way governments should and must act, however, is first with careful collection
and evaluation of all available evidence -- for example, as this committee is
In the case of Bill 11, there is very great evidence from New Zealand,
Australia, and Great Britain about the effects of increased privatization in an
otherwise public system. Further, there is evidence about Alberta's own practice
of mixing public and private care regarding ocular surgery for cataract
When this information was raised in debate, it was summarily dismissed.
Indeed, most of the researchers who have presented such information have
actually been called such unsavoury names as "whiners, complainers, and
The Chairman: That is minor compared to what members of this committee have
been called. It is hard for us to be sympathetic.
Dr. Shanner: There is always going to be disagreement about values. There
will always be disagreement over how to set the priorities. There will always be
times in which all of us will tend to act out of what we are used to and
comfortable with, rather than going back to the beginning and thinking it all
the way through.
In the example of capital punishment, for instance, the moral argument
supporting the death penalty is really rather dodgy. Does the death penalty
deter crime? The answer, through evidence, is clearly no. Is the death penalty
cheaper than incarceration? The evidence indicates no, it is not. Is there any
good reason to commit capital punishment, short of seeking vengeance out of the
anger of those in the community who have been hurt? Since that is the only
reason to go forward, and the reasons against continuing the death penalty are
significant, the best answer is to end the death penalty and lead the public
into revising its opinion based on a better discussion of what is known.
The problem with Bill 11 is that there is quite a lot of information. It is
being discussed by a large percentage of the population, but not effectively at
the policy-making level.
Further, what is the justification for Bill 11? There does not seem to be
much. The main benefit will be to regulate contracts with private facilities.
This speaks only to surgeries. It does not speak to private diagnostic
facilities, private clinical facilities, physiotherapy centres. There are all
kinds of private facilities. This bill does nothing to address that very
legitimate concern. In fact, what it does primarily is open up overnight stays
at for-profit private centres, which the government's own blue-ribbon panel last
year identified as "hospitals." A non-hospital hospital remains a
Third is the concern about the use of coercive forces and manipulative
language. If this is worth doing, let's talk about why. Simply to use slogans or
name calling or to refuse to discuss the other side of the question is simply
not an appropriate approach.
Those are my concerns.
The Chairman: On that basis, you would disagree with the vast majority of
major legislative approaches by governments of all parties, federally and
provincially, if you think that the use of slogans, party whips, and a variety
of other things are not appropriate mechanisms for changing public policy. I am
not even sure I disagree with you on that. I merely observe that much of what
you have said would apply to a whole variety of things done by all parties
across the country.
Let me make one other, general comment. I would like to move away from Bill
11 for a minute.
There is an implicit position, and perhaps in the case of Professor
Somerville it was explicit, that in many of these questions there is a
Dr. Somerville: No.
Dr. Shanner: There are better answers and there are some that are clearly
The Chairman: "Better" is a value judgment. If I give you five
answers, you can tell me that one is better than the other. In many of these
issues, there is a judgment at the end and it is difficult to classify it as
better or worse, since better, inevitably, has to be based on the
decision-maker's personal values. I do not know how you avoid that problem.
Dr. Somerville: I would like to comment on the previous issue that you
raised. It is true that you cannot establish ethics by consensus. If you could,
the Nazis would be ethical. That is an easy example.
It is also true, and something that we have realized very much more of late,
that it makes a vast difference whether we start our analysis of an issue with
the law and then consider ethics, as we usually do today, as compared with
starting from ethics and then considering law.
The Chairman: I will agree with that.
Dr. Somerville: If I may say so, one of the differences between your position
and Professor Shanner's is that she is starting with ethics and then saying,
"Having established the ethics, what law should we implement?" She
finds Bill 11 unsatisfactory because of her ethical reservations. You say,
"Let's use the legal process and see what happens."
Another point I meant to raise in my presentation is that we are very
concerned about the ethics of interfering with medicare. I think that is the
right approach. On the other hand, we have to be equally concerned about the
ethics of denying access to private health care. That does not mean we should
make a decision to do that. What it means, and this relates to your question, is
that in doing that, we cannot just ethically say that is what we choose, and
like it or not, we are going to have it. We have to be able to ethically justify
that inhibition/prohibition on private health care. I am not sure that we will
be able to do that in the future.
It will be a very complex debate, particularly since the governing ethics
will be different at different levels.
To respond to your question about whether ethics is just what I prefer. No,
the whole point about ethics is that it is not just what I prefer. It is a
structured, analytical approach to a conflict. There are different values and
different positions. You may well come out with totally different answers to the
same question, depending on the ethical structure that you use for your
analysis. However, you must be able to justify your choice. It is the
justification of that choice that makes up the ethics.
Almost all of these questions are value judgments, which is why we have a
conflict. If we all come to the same answer, we get what we call the "white
light of ethical insight," but that does not happen.
Senator Keon: You began to answer the question I was going to raise. Moving
again to Bill 11, the big issue facing us all right now is the ethics of holding
a population hostage to a single-tier system.
Let me give you an example. I am frequently called by people who need a
certain procedure that they have been told they cannot have in Canada under
general anaesthesia. They want to know where to go in America.
Is it ethical for us to have decided that some apprehensive person cannot
Dr. Somerville: The dean at one university wrote to me wanting a copy of a
book entitled Canadian Health Care Policy. One thing he said in his letter that
gave me a shock in the realization of it, was that Canada really does have a
private health care system, only it is in the United States, unlike Australia,
where it is too far to go to access another system.
I think you are making a very important point. I certainly cannot answer
whether it is ethical or not. I could, at some point, try to do an analysis of
whether it is ethical to continue to do that.
That is exactly the point I was raising. We cannot simply assume that it is
ethical to do that. We have to be able to justify that it is ethical. I do not
know whether we are going to be able to do that. It is the issues that Professor
If your primary value is equality of health care for the Canadian population,
you may feel that we should provide for all basic needs and not go beyond that.
You could possibly justify it. On the other hand, there is this joke going
around in Ontario about a man who booked himself into a veterinary clinic with
the last name of Fido because then he got a CT scan the next day, whereas he
could not get it in the hospital for several months.
If you can spend your money on your dog, why should you not be able to spend
it on yourself, if that is what you want to do? The reasons are societal. There
are value reasons. There are social cohesion reasons, and there are
community-forming reasons. That is why we have such an incredibly difficult job
in doing this.
Dr. Shanner: If I could add, there is a real tension between this level,
which is the policy for the community, and the health care providers level,
which is at the bedside with individuals. Health care providers are committed to
doing the best for the patient, and their job is to move mountains to get that
procedure. When it is not available, the clinician is unable to do what is
needed, and may be thereby constrained from meeting personal ethical
requirements. There is a very difficult level issue already, in that whatever
you decide, you must not undermine the ethical commitment of the care providers
The other piece of this is that allocation decisions are not appropriately
made at the bedside; it must be here. By the time an individual says, "I
need a procedure but I cannot get it. What will you do for me?", the
problem, and the ethical failing, has already occurred.
We need to step back several levels. There are larger questions, and again I
do not have answers for them. We need a very serious, community-wide
conversation about what are the goals of health care? This affects everything,
including how research monies are invested and what kinds of health care
problems and technologies we will pursue. Do we expect significant benefit, say,
to justify the enormous amounts that we are investing in genetics research? How
do we deal with questions about repeated treatments, people with chronic
conditions who come back again and again, and who end up using vastly more
health care resources than people who are generally healthy but experience the
occasional crisis situation?
We have questions about age. How do we deal with neo-natal intensive care?
How do we deal with the increasing age of the population demographically? Are we
going to institute an age limit beyond which we will not provide care and you
are on your own, or do we say it is for all ages? There are limits that need to
be imposed. It is not an age question, it is something else. However, what is
that something else?
We need your leadership to help answer those questions in the community. Help
us with that conversation. When we have to say no, to whom do we say no, and
what is the justification? We cannot do everything for everyone.
Dr. Somerville: It is a very real and current problem, as we see if we look
at the Supreme Court of Canada's major judgment on informed consent in a case
called Reibl v. Hughes. There is another one, Lepp v. Hopp. Under that, the
physician has to tell the patient all the information that would be material to
a reasonable person in the same circumstances.
One of the things that is material to patients is knowing the possible range
of treatments for what is wrong.Usually the patient questions what is best and
what is worse. Physicians, at the moment, are restricted by health care budgets
in the hospitals. Sometimes, what would be the best thing to do is not even
What does that physician do? A lot of physicians are fudging it and do not
say much about it. Legally, quite apart from ethically, that physician is not
obtaining informed consent when he or she does that.
I gave a lecture based on this paper the other day, and I had people from the
hospitals falling under the table saying, "You mean you want us to tell
patients about treatments that would be good for them, but that we cannot give
them here?" I said that it was their legal obligation to do so. It is also
their ethical obligation. One of these doctors said that it was already tough
enough practising medicine, it would be impossible if they had to do that. In
fact, that is what they should be doing, and some doctors are. It is very, very
The Chairman: Senator Carstairs has had an example of that in her family
Senator Carstairs: Quite frankly, the doctor was very ethical and said these
are the options -- radiation, surgery, and therapy. He said that he could not
administer therapy in this country for prostate cancer, since it was not
available. He outlined all three. When I asked him what would he do if he were
in that situation, he said he would have the special therapy. We went to the
United States and had that therapy.
Dr. Somerville: I am sitting on the health technology assessment group at
Health Canada. We had a meeting last week. There is a new technology out that
Dr. Keon will know about. It is an implant device, and theoretically, it could
save the life of anybody who has had any kind of heart trouble. One estimate of
the cost of giving it to all Canadians who could benefit from it is that it
would use between 4 and 5 per cent of our total health care budget -- one small
We are dealing with the issues we see on the front pages of our newspapers.
These are just the tip of an enormous iceberg.
Dr. Shanner: I will mention one last item to call attention again to issues
that Dr. Millar mentioned earlier. All acute care services, everything done in
hospitals and most of what is done in doctors' offices, account for about 15 per
cent of our health status. If we want to be healthy Canadians, and if we
seriously want to reduce how much we spend on our health budget, we will have to
work in areas outside that budget. We need to focus on poverty relief,
education, cleaning up the environment, and that long list of other social goods
that create the conditions in which we experience health or illness.
There is another aspect to this. We should, perhaps, not focus on the
patients, for whom wonderful intervention might be available, but we could only
provide a few without bankrupting the country. Instead, we should step back and
consider not just what is most effective in health care, but also how to keep
people out of the acute care system in the first place, while maintaining a
robust health care system for crisis situations that were not preventable.
Dr. Somerville: The only thing you can say about that is that maybe we have
the wrong terminology when we say "health care," because that focuses
on what we are doing about health. Actually, we are talking about illness care.
It is, as Susan Sontag says "the kingdom of the well and the kingdom of the
sick." We are dealing with how to treat the people in the kingdom of the
sick. We get into a mess when we start to bring all these other things into it.
Senator Fairbairn: We could continue for hours on this topic. As I listened
to you use key words such as value judgment and trust, another element struck me
-- how to define ethics or offer ethical protection? There is also the ability
of the people to understand the layers in the definition as well. This
encompasses all of the additional issues such as poverty and lack of
opportunity. However, with all the ethics, best practices, and goodwill that we
can come up with, we are also looking at a great number of people who will not
understand it, except perhaps in the most fundamental way. This is leading to
the issue of wellness and illness.
Also, in consideration of what we have gone through and will continue to go
through, there is another important issue. At the heart of a lot of the concern,
which has come, certainly, in the form of organized demonstrations -- people
just coming out to express themselves -- is there not a question of fear?
Dr. Shanner: Yes.
Senator Fairbairn: It really may be a lack of understanding, knowledge, and
ability. There are many people who can use the Internet, as I have myself, and
find a vast array of suggested new developments, but there are just as many
people, not just in this country but in this world, who have no access to that
part of the debate.
Those are my thoughts. The one that always comes through, when it comes to
health, is the primal feeling of anxiety and fear, because there is nothing more
Dr. Shanner: I think that you have two really wonderful, rich questions
blended together. On the first, about who can understand all of this, there are
two things to consider. One encompasses the areas of knowledge -- economics,
politics, and the outcomes data. Very few people understand much of any of this
at all, let alone the whole picture. The second part of this we might call
"wisdom," which has nothing to do with knowledge or power. This is
what you learned at grandma's knee about what is important in life. There is
quite a lot of wisdom among those who are not in positions of power, knowledge,
or authority. I think that your insight about the fear that arises when health
is on the table is both instinctive and entirely reasonable. When your health is
at stake, nothing else matters. Everyone pretty much recognizes that.
When we are reasonably healthy, we get distracted and we take our good health
for granted. We worry about other things, such as paying bills and advancing in
our jobs. It all comes to a screeching stop when we get sick, and suddenly it is
very clear just what is important here.
I want to emphasize not only that recognition of the value of health and
health care, but also a lot of the core ethical values. I am giving you some
technical words here, but they really come down to: Do not pick on people, do
not hurt them, do not kill them; and treat other people as you yourself would
like to be treated. When you and your little brother shared the piece of cake,
you divided it fairly. Help people. There is an understanding of integrity and
honesty. If we did not learn this as young children, then I would have nothing
to teach. I can only give it a name and call attention to the inate wisdom, or
the wisdom learned very early, about what it means to live a good life and be a
Those who have utterly no interest in philosophy may have an interest in
religion. It is the same concept and is another explanatory system. It is a
search for the good and how to make it manifest in our lives. People understand
this, although they are very easily distracted.
The other piece, the public fear, again gets back to the process. We are
completely vulnerable when we are ill because of fears related to disability or
the loss of life. As citizens, we are, in a way, vulnerable to our policy
leaders. When the policy leaders are not listening, not taking seriously how
anyone else perceives this or experiences that, and decline to discuss the
issues relevant to health care providers, then we have a situation where the
lack of trust and powerlessness is much greater than in health care itself. I
believe that it was the powerlessness and the undemocratic process that were
being protested in respect of Bill 11. It is not just about health care in
Alberta any more, it is also about whether the government is responsive to the
people, and to those who are sworn and committed to help them.
Those are two different issues that are separable but very closely connected.
We have seen the connection and the evolution in Alberta very clearly.
Dr. Somerville: I think one of the things that we have to do is look at the
changes that have taken place in our society and how those changes are altering
the context in which we deliver health care.
For instance, it is often said that our society is based on intense
individualism. That means, for example, that with all the talk about rights to
personal autonomy and self-determination, the individual's claims are given
priority over the claims of the community. If we looked back to when we founded
medicare, we might find that there was quite a different balance between
community and individualism. We need to look at who the people are. We have seen
an incredible increase, in the last 12 months, of cases in our Canadian courts
where people have sued somebody to obtain health care. This has happened only
recently in the United States as well. We have to ask why that is happening. I
think one of the reasons is the baby boomers. They are well educated and
articulate, feel that they have rights, and are used to getting what they think
they need. There are all sorts of things that we have to look at to see why the
situation is different now from what it was when we started medicare, and how
that can be accommodated.