November 2009

Re: “Too Much Health Care,” by Charles J. Wright

Dr. Charles Wright’s essay puts forward a notion that will be viewed as heresy by all of the vested interests in health care who clamour ceaselessly for more money for doctors, nurses, drugs, diagnostics and nearly everything else. By any objective measure the Canadian healthcare system is well funded. At 11 percent of the gross domestic product, Canada is spending as much or more than every other country with a universal, publicly funded healthcare system.

Wright makes the point that we are not spending that money effectively. I agree. We are overspending on drugs and underspending on patient education. We are overinvested in old technologies. We are overinvested in old ways of doing things and vastly underinvested in the innovation needed to modernize our health services. There are some promising signs:

• reformed primary care with nurse practitioners, physician assistant, dietians and other providers joining the team;

• modernization of health technology particularly diagnostics;

• more decision making based on outcomes; and

• patient safety becoming a priority.

I have one criticism of the article. The negative comments on screening may be confusing to many patients. Screening for at-risk groups has a different hurdle than population screening. Some tests such as PSA are unreliable for screening but may have utility in diagnosis. Greater clarity is needed.

However on the most important point in Wright’s article I agree. Appropriateness is not a central principle of health decision making and it needs to become one. The 440 million diagnostic tests ordered by Canadian doctors for their patients last year are not subjected to a high enough hurdle on appropriateness.

Wright concludes his piece by noting “we have to recognize the paradox that increasing healthcare interventions can cause more harm than benefit, and take an intelligent, evidence-based approach to setting limits not only to funding but also to what is in the best interests of people’s health.” This is the hard challenge. Setting limits is easy to say and very hard to accomplish.

It is very difficult to speak out on “harmful” interventions or overuse due to patient fears of “government rationing.” There is well-documented evidence of overuse of diagnostics and drugs but it is hard to build a consensus that is not undermined by the first compelling patient story that makes the front page. Dr. Wright’s advice is sound and should be heeded by healthcare leaders as well as patients—too much of a good thing is possible even in health care.

Michael B. Decter

Dr. Charles Wright describes Canadian health care as publicly funded insurance to cover “all necessary medical services.” He declares that limited funding makes it impossible to sustain the growth of those health services and then questions the appropriateness of some of the services available.

Here is what I know from my own practice. Recent medical advances in neuroradiology, my subspecialty (imaging of brain, neck, spine), are now normal: computed tomography (CT), magnetic resonance imaging (MRI) and the treatment of brain aneurysms from within the blood vessel, platinum wire coiling. Imaging for all organs and all cancers has been revolutionized, including the detection of breast and prostate.

As Wright describes, we detect cancers that might never cause trouble along with virulent ones. However, care for cancer victims should not be suppressed because we do not know which cancers will prove to be dangerous. Surely it is more appropriate to call for research to develop markers to distinguish risky cancers.

It may take decades to get answers. Focussing on costs would deny us the benefit of advances until the most rigorous research trials can tell us which cancer victims will survive without problems. Who would have the nerve to withhold treatment to watch Canadians die before the studies distinguish which is which? That is what the anti-Obama factions claim about our healthcare system now, but it is not true yet.

There is another complication. In my field, we have moved from simply showing disease to also showing its absence. People with chronic headaches suffer. Experts traditionally rule out serious causes by thorough physical examination, including examining the back of the eyes and exclusion of neurological physical findings. Thirty years ago, experts had confidence in their own diagnosis when classifying headaches. Twenty years ago, they would order a CT—which almost always found nothing. Today, the same patients often have an MRI—to also find nothing. It is as if doctors and patients need more and more images simply to exclude the worst possibilities before they progress further. But perhaps good imaging has replaced full physical examinations. Rather than assuming overuse, it seems appropriate to study changing practices, including a reduction in time needed for physical exams thanks to imaging.

Here is a different idea: How about selling “convenience” (i.e., priority service) to provide sorely needed revenues for facilities to provide more services for everyone? For example, imaging facilities face great demand and wait lists, yet the machines are still not fully utilized for lack of operating funds. If a few patients every day would pay for convenience, there could be increases of operating funds to provide for more patients every day per machine. What is wrong with finding new revenues to help provide scarce services?

Allan Fox, MD
Toronto, Ontario

In “Too Much Health Care,” Charles J. Wright argues that expensive, ineffective drugs be de-listed from provincial health schemes, concluding that “the potential benefits are just too little and the costs too enormous to justify public funding.”

If there is no good reason for taxpayers to fund expensive, ineffective drugs through not-for-profit health schemes administered by provincial governments, then there is also no good reason for employees/employers to fund those drugs through for-profit health schemes administered by insurance companies.

Instead of merely de-listing such drugs from public health schemes, we should de-license them entirely. Then the question of payment for such drugs becomes quite irrelevant, since no doctors will be prescribing them.

Think of the benefits:

• Immediate reduction in the cost of drugs currently used for health care.

• Long-term increase in the effectiveness of drugs developed and brought to market.

What does Charles J Wright think of this small extension of his conclusion?

William Hayes
Port Hope, Ontario

A Response from the Author

I am very sympathetic to William Hayes’s suggestion. But preventing individuals from doing whatever they want with their own money is very difficult in a free and open society like ours. We cannot prevent a wealthy person or family from paying huge sums of money—whether directly or through insurance—for a small chance of receiving a very doubtful health benefit. We can, however, give the public accurate information on the dismal results, and we can draw the line at public funding.

Charles J. Wright, MD, MSc, FRCS (C,E,Ed)
Toronto, Ontario

Re: “We’re Still Watching,” by Paul Wells

As the author of a biography of Robert Borden and another book about his governments, I am gratified that Paul Wells wants people to read books about Robert Borden. Alas, Wells appears to be unaware of my books, not a great fault, but, more seriously, seems oblivious to the existence of what he calls “a great big book” about Borden. That book exists: a definitive two-volume biography by Craig Brown, one of Canada’s finest historians. Written four decades after Borden’s death and 60 years after the conscription crisis, Brown’s book apparently tells Canadians, Wells apart, more than they want to know about Borden. His splendid biography, like my own less worthy effort, is now out of print.

The great issues of Borden’s era are now far in our past: the British Empire has died; the conscription crisis is far away; the Tories are now free traders; and Canadian “independence” is defined as distance from the Americans not the Brits. But Trudeau haunts us still. The American Empire endures, multiculturalism roils our politics and the Charter of Human Rights and Freedoms infiltrates our daily lives. Trudeau fascinates us because the choices he made deeply affect us. The journalist Wells seeks final judgement but limbo is sometimes more appropriate for a historian.

Wells complains about the length of Just Watch Me: The Life of Pierre Elliott Trudeau, 1968–2000 but then asks for more words about the times when he toiled in Ottawa but Trudeau did not. As Sacha Trudeau commented, Trudeau never discovered creativity and energy outside of the prime minister’s office. His interventions in Meech and Charlottetown were a sudden efflorescence that briefly illuminated Canadian politics after 1984, but Trudeau’s significance for a biographer lies in his accomplishments and failures when he was prime minister. He changed little after 1984, but Canada did.

Finally, Wells suggests that Just Watch Me contains the seeds of “a delicious revisionist Trudeau history,” which would depict him as “flighty, clueless on the economy, racked by domestic unhappiness and too easily romanced by fancy theories that did not work in real life.” Wells evidently has a taste for stale seeds. They were planted long ago in Calgary’s Petroleum Club, fertilized in many university common rooms, gleefully nurtured in several editorial board rooms including those that have paid Wells’s salary, and are now fully in bloom at 24 Sussex Drive. It is an old tale too often and badly told. Surely a truly revisionist approach points to a highly disciplined leader, acutely sensitive to changing political winds and highly resistant to theories emanating from Chicago and his own finance department that, implemented under his successors, appear to have made real life much worse for most of us.

If Paul Wells is not too much affected by our current economic woes, he’s welcome to buy my remaindered Borden books at a fraction of their price at used book stores.

John English
Waterloo, Ontario

In the movie Butley, Alan Bates plays a randy, exceptionally ill-clothed professor of English out to bed a student. One line he uses to impress her is, “I really hate to have to give a lecture on a book I haven’t read.”

Absent the girl, my present task is somewhat similar. It is to review a review of a book that I have not read yet—John English’s second volume of his biography of Pierre Trudeau, Just Watch Me.

So I’ll just assume that Wells is entirely accurate in his description of the book itself, namely that it is comprehensive and rigorous and balanced and fair, but overly judicious or lacking in bite.

The outstanding question then becomes whether Wells is right to say that rather than another biography of Trudeau, what we need is a biography of Sir Robert Borden.

Borden was competent and worthy. But introducing rural mail is not enough. Okay, okay, Wells was only using Borden as a teaser. His real thesis is that we have had more than enough of Trudeau.

He has a point, up to a point. Trudeau no longer “haunts us still”: time does that to everyone.

But of all our prime ministers, only two actually interest Canadians: Trudeau and Sir John A. Macdonald (about whom I admit to a potentially disqualifying “interest”).

The interest is justified. This has nothing to do with the stuff Wells seems to be exercised about, such as lousy economic policy or that multiculturalism upset some Quebec intellectuals: stuff happens.

What mattered about Trudeau then—still does—is that he challenged us, stirred us up, gave us bragging rights we had never before imagined we might possess. He communicated to a great many Canadians his belief in the pursuit of excellence for its own sake. He dared Canadians to stick their heads above the parapet that, for the preceding century, was as un-Canadian as you could get.

Wells does have a perceptive point to make, but buries it in his closing paragraph. This is that what’s really needed is a book on Trudeau by “a Russian novelist.”

Or by a Canadian one. The imaginative challenges would be to capture how it was that Trudeau animated the rest of us far beyond what we were when he came in, including by reminding us that prime ministers remain sexual beings.

He animates us still. However, Wells has a case that we may need a good new biography of Borden.

Richard Gwyn
Toronto, Ontario

Re: “Freedom Redefined,” by Daniel Marc Weinstock

I am grateful to Daniel Weinstock for his generous and insightful review of Public Philosophy in a New Key. He concludes with an important question:

There is a lack of fit between this [Tully’s] indignation and Tully’s view that there are no standards of justice that are independent of historically contingent language-games … Aren’t judgements about the horrific treatment visited upon the planet’s most vulnerable peoples actually fuelled by a sense of what justice requires, rather than by what justice happens to mean in this or that language game?

The question makes it appear that, when individuals or groups raise a claim of justice, they are doing something more than raising a claim in a language game. I wonder if this distinction can be sustained once we understand the meaning of a language game.

First, a language game comprises both the language (the relations of communication and knowledge) and the game (the activities and power relations) in which a claim of justice or injustice irrupts. It is the whole practice in which any agent, by means of an act of “civic freedom,” makes a justice claim. Next, a claim is taken up and tested for its validity in more specific language games of critical testing and justification. These claims-testing practices are multiple. They include courts, legislatures, tribunals, dispute resolution practices, truth and reconciliation commissions, investigative journalism, freedom of information, official and counter public spheres, protests, Satyagraha, revolts, academic justice-testing practices from Plato to Sen and everyday conversations. Third, within any testing practice there is the critical freedom of the participants to call its standards into question and subject them to critical scrutiny, thereby modifying and improving the practice en passant. Hence, to say that a justice claim is valid relative to the language games available to test it means that it can survive the best available testing practices and critical reflection on their standards.

The pragmatist tradition argues that this is the best way to think of justice claims. It orients us to the multiplicity of existing testing practices as the grounds of a claim. It thereby refuses to stop at a formulation of a claim that exempts it from testing by presenting it as beyond question (as a self-evident truth, unmediated word of an authority, universal, necessary or without alternatives). Yet it also makes us aware that the practices which give claims their degrees of validity are not transcendental but only the best possible ones here and now. History teaches us that these often turn out to be less than perfect when put to the test of critical freedom.

These features of justice and justification may appear too humble for those who require justice claims to be beyond question. But we could reply that such a requirement is politically dangerous. Rather, it is justice itself that requires us to take up this Socratic testing ethos to claims and counter-claims. It is the basis of a just world.

James Tully
Victoria, British Columbia

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