Medical Care


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Self Responsibility

Self responsibility is a familiar concept in Canada, but when it comes to medical care, the concept vanishes. Each person has some control over their life course and some ability to prevent injury and disease. Diseases often emerge because of ignorance or careless disregard for risky behaviors.

There is a compassionate basis for medical practice. The idea is to receive the sick and injured without judgment, patch their wounds, treat their diseases and alleviate suffering when there is no effective treatment. The government of Canada took the compassionate idea and legislated that, whatever the determinants of injury and disease are, the doctor and the hospital are ready to attempt rescue you at public expense.

In debates about the Canada Health Act, critics pointed to the lack of any personal responsibility. They described the need for responsible use of public resources and also the need for well informed prevention and self management. They compared a medical care card with a Visa card that you could use to purchase whatever you wanted, but you never had to pay. The critics' prediction of escalating costs has proved to be accurate.

For many years MDs were blamed for escalating costs and draconian measures were invented by bureaucrats to intimidate and control MDs. When MD control proved to be unsuccessful, users access to resources were curtained by limiting resources and using waiting lists. The Canadian system has been examined in detail, repeatedly and its shortcomings revealed in voluminous reports that fill libraries. Numerous studies, government hearings, conferences have looked at the Canadian system. The Canada Health Act needs revision but no government will improve that status quo. The terms “ Health Act and Health Care” misrepresents health in every possible way. Health is supposed to refer to being “healthy” – free of disease, physically fit, productive and happy. Healthy people do not need to spend money on doctor visits, tests, drugs and surgery. Canada needs more healthy people and less medical care.

One missing ingredient is self-responsibility. Since everyone is blameless, any and all misadventures are tolerated, even encouraged. The supply of medical problems increases without end. Some injuries and some diseases are indeed blameless and any good person will want to help the victims. But some diseases and injury are self-inflicted and are preventable by well-informed self-responsibility.

Even if prevention fails, diseases such as diabetes 2 require well-informed self-management. The American Diabetes Association published revised Standards of Care for diabetes emphasizing that high-quality diabetes care must be individualized to reflect the needs, interests, and abilities of each patient. Patient education and motivation must be a central component of quality diabetes care because the patient must provide daily self-care such eating properly, monitoring blood sugar levels and fulfilling exercise requirements.

The most obvious failure of self-responsibly are the diseases caused by drinking alcohol and smoking tobacco. Legislation and public health measures to reduce smoking have been somewhat successful. Smoking diseases are being replaced by food diseases. Alcohol diseases remain a major problem and mitigation of cost and consequences remains a responsibility of police who enforce laws that limit access to alcohol and detect and punish drinking drivers. In some trauma centers, drunk drivers are responsible for over half of admissions.

People in the US and Canada are not healthy because they eat too much of the wrong food and exercise too little. The mechanisms of bad-food diseases are numerous and complex. Marketing chemicals to reduce the negative effects of eating too much of the wrong food is profitable for drug companies and a burden on individuals or their insurers. In an ideal world, fewer drugs would be required.

The real solution is not taking drugs, but eating less, choosing the better foods and exercising more. The caveat, of course, is that most humans will not take charge of their own destiny. They are members of groups that set the stage and write the script that each person follows. I have learned that humans generally do things that they should stop doing. In addition, I have learned that reasonable, rational solutions to human problems are seldom pursued for very long.

Proposals for universal medical insurance have surfaced again in the US campaigns for the 2008 election. Again, the idea that the government would become a master insurance agency and pay all medical bills is not very appealing. Physician and law professor Gregg Bloche summarized an emerging ethic that requires more self-responsibility.

‘The trend is toward an ethic that calls on us to take care of ourselves…this ethic includes high-deductible coverage, financial rewards for regular workouts and weight control, and penalties (such as premium surcharges) for failure to comply with treatment. If the United States is to come close to universal coverage, personal responsibility will need to play a larger role than it did in the mid-20th-century welfare state. The new compact is likely to start with an enhanced sense of individual obligation — to eat sensibly, exercise regularly, avoid smoking, and otherwise care for ourselves. It may include an obligation to buy insurance. Government, in exchange, can offer some protection against the threat of economic and social change that will disrupt people's coverage by destabilizing employment and family relationships. Not only can the state provide subsidies to enable poorer citizens to buy insurance; it can, at low cost, combine people's purchasing power and clear away obstacles to competition, empowering markets to extend coverage to tens of millions who now go without it. Government can also fashion incentives to foster evidence-based practice, health promotion, the elimination of racial disparities in care, and the reduction of medical errors.”

Carolyn Clancy, director of the US Agency for Healthcare Research and Quality stated: Patients are becoming more involved in decisions about their care. Even though this is a major change to how we (MDs) practice medicine, it will, over time, create a genuine partnership between doctors and patients…we recognize the importance of clear, ongoing communication, including questioning why a particular treatment decision was made. My agency has developed a new public awareness campaign with the Ad Council to encourage patients to take a more active role in their healthcare.

M. Gregg Bloche, M.D., J.D. Health Care for All? New England Jour Med. Volume 357:1173-1175 September 20, 2007 Number 12

Carolyn Clancy. How Do We Involve Patients in Their Own Healthcare Decisions? Medscape Online Posted 11/30/2007


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