Why your health isn't your own business

How much is your life worth? Oh dear me no. I don't mean to you or your family. I mean to the Finance Ministry. You see, news out of Britain informs us that their government just isn't willing to spend that much to save lives. The National Institute for Health and Clinical Excellence (known scarily as NICE), which has already rejected various expensive drugs available in the U.S. and elsewhere in Europe, has now formally declared that "There is a powerful human impulse, known as the 'rule of rescue', to attempt to help an identifiable person whose life is in danger, no matter how much it costs. When there are limited resources for health care, applying the 'rule of rescue' may mean that other people will not be able to have the care or treatment they need. ... The Institute has not therefore adopted an additional 'rule of rescue'."

Of course government health providers should try to control costs, especially when medical care now consumes, not untypically, 46 per cent of the Ontario budget. And they have been trying in Canada, since at least the ill-fated 1992 decision to cut medical school enrolment by 10 per cent to reduce the number of doctors treating people and submitting bills. One is tempted to file it under "Be careful what you wish for." But the crucial point is that you didn't wish for it. They did.

Which takes me back to a century-old warning from Albert Venn Dicey about a then-novel wave of legislation intended to protect citizens from their own poor judgment or weak bargaining position, real or imagined. "The point is elementary," he wrote, "but it is worth insisting upon, since there is a constant tendency on the part both of theorists and of so-called practical men, to forget that protection invariably involves disability, i.e., limitations on the individual liberty of the protected person."

I remember when it was those on the "right" who had to insist that we think sensibly about tradeoffs in public policy. Thus Thomas Sowell once asked in exasperation: "Would anyone really spend half the Gross National Product to wipe out the last vestige of shop-lifting, or every minor skin rash?" But NICE is hardly conservative. And while Dicey's massive white beard and solemn praise for the Victorian constitution might tempt us to classify him as conservative, reactionary, even a fogey, as a Benthamite defender of political innovation in the name of laissez faire he doesn't quite fit today's pigeonholes, despite dating from an era when desks actually had such. So let's just read his words and see if they tell us anything.

They tell us that when the law prevents us from doing something that might be contrary to our interests, the tradeoff for the possible protection is the inevitable prevention. In this case, the prohibition on buying and selling medical care in the free market might protect you from being unable to afford it, buy more than you need, get worse care than the rich, etc. But in doing so it necessarily prevents you valuing your own life or health more than the government does. Which is every bit as bad as it sounds.

As things stand, you do not merely pay for health care what Dalton McGuinty says you should. You get the treatment he makes available to you, when and where he makes it available, of the sort and in the quantities he makes available, and nothing else. And if you don't like it, you cannot take your business elsewhere. It has, in every important sense, ceased to be your business.

If you were responsible for your own health care you would, of course, try to ensure cost control, as I presume you do in every aspect of your life with varying degrees of determination, skill and success. You'd want to look after yourself but you'd also want a car, a home, education for the kids, a retirement fund, a bit of bacon in your porridge and a decent chance of living long enough to enjoy all these good things. In short, you'd worry about getting the right mix of cost and service.

When you hand over health care to government, or your fellows do it for you, these still-necessarily value-for-money calculations are not merely done by someone else. They are also done very differently. They are generally not done well, for familiar reasons that need not be reviewed here. For now consider only that, even if the state did not have serious problems making rational tradeoffs, public servants and politicians would still make their calculations of efficiency based on different criteria.

Including, most importantly, that if you died they wouldn't miss you nearly as much as you would. But they'd sure miss the money needed to treat you. And you'd better think about that, because they are.

[First published in the Ottawa Citizen]