Volume 13, Number 1, 2003

The Exploitation of Canadian Values - “Building on Values”, the Romanow Report

Richard C. Fraser, Q.C.
LLB, University of Alberta
LLM, London School of Economics
Adjunct Assistant Professor, John Dossetor Health Ethics Centre, University of Alberta

The prescription for Canada’s ailing health care system has arrived. A remedy has been found. According to Roy Romanow it is contained in his report that cost Canadians $15 million. He has declared that “the system is as sustainable as we want it to be.” (Romanow, 2002) In other words, as Canadians, we can look forward to governments spending their way to success. Mr. Romanow has already called for the federal government to spend budget surpluses on health care funding beginning with a $15 billion payment. As Rex Murphy correctly points out “$15 billion is just a down payment. It is a mere installment” (Murphy, 2002). This proposal will ravage expenditures for everything else from education to much needed infrastructure.

However, to disagree with Mr. Romanow’s views one risks being accused of betraying cherished “Canadian values” as determined by Mr. Romanow. These values, along with Mr. Romanow’s political and social agenda are contained in the 356-page Romanow report entitled “Building on Values”. Norman Spector reminds us: “Be vigilant, and hold on to your wallet when your leaders go on about “values” but refuse to talk about value for your money” (Spector, 2002).

The failure of the Romanow report lies not only in many of its recommendations and messages but more importantly in how these recommendations and messages were delivered. They were delivered veiled in an emperor’s clothes of values that were meant to give them the imprimatur of legitimacy. There was to be no room for challenge or debate. This exploitation of values has the effect of stifling legitimate debate over the Romanow report’s recommendations, and the supposed values it espouses. Mr. Romanow’s recital of Canadian values is at best anecdotal, including such sweeping statements as:

  • “In their discussions with me, Canadians have been clear that they still strongly support the core values on which our health care system is premised – equity, fairness and solidarity. These values are tied to their understanding of citizenship.”
  • “They connect with the values that define medicare, not the particular features of the system in place in their province or territory.”
  • “The reality is that Canadians embrace medicare as a public good, a national symbol and a defining aspect of their citizenship.”
  • Canadians view medicare as a moral enterprise, not a business venture.” (Romanow, 2002)

In stark contrast to Romanow, four other recent health care reports did not resort to quoting ‘Canadian values’ to justify recommendations. Instead they did the system and policy analysis required to arrive at concrete and workable health system reform. Their introductory messages are telling:

  • The Clair Commission (Quebec, December 2000), “We propose that these two obligations – to make choices and perform – be met with a new vision for the future rather than with nostalgia about old paradigms…We wanted to go beyond cliches.”
  • The Mazankowski Report (Alberta, December 2001), “This report is not about quick fixes. We’re looking at the best ways to sustain the system over the longer term not necessarily to reduce costs in the short term. Nor is our report about broad general ideas or approaches. It provides practical ideas and solutions to address problems and ensure sustainability of the health system for years to come.”
  • The Fyke Commission (Saskatchewan, April 2001), “All parties have, to varying degrees, underestimated the fragility of Medicare and have focused on their own entitlements rather than their obligations….There are many recommendations in this report about structure, organization, quality, and standards. Success will follow only if there is a change in perspective, behavior, and rhetoric.”
  • The Kirby Committee (Canada, October 2002), “The Committee believes that its recommendations meet the four objectives set… 1. To formulate a detailed, concrete plan of action. The recommendations should not focus primarily on governance issues or intergovernmental structures; 2. To attach a cost to the Committee’s recommendations and propose a specific revenue raising plan; 3. To specify clearly the changes that each of the major stakeholders – individual, Canadians, health care professionals, provincial and federal governments – would have to make in order for the Committee’s reform plan to be successfully implemented; and 4. To make clear the consequences of not changing, and hence of not reforming, the health care system.”

These four reports rejected the premise that you can spend your way to success. As well, they also at least took the first tentative steps to suggesting that we measure and pay for outputs and not inputs.

The handling of the wait list issue was a defining moment for Romanow. In this area he offered little comfort for patients stuck on lengthy waiting lists across this country. Instead of calling for guaranteed timeframes (outputs) for wait lists, as did Kirby and Mazankowski, he called for a guarantee of funding (inputs). This was in spite of Romanow’s acknowledgement that “the advantage of care guarantees is the certainty and reassurance they provide to patients” (Romanow, 2002). Romanow’s sop to patients, after rejecting “care guarantees”, was to grant that “patients also have a right to good information about how long they can reasonably expect to wait for treatment and what other options are available to them” (Romanow, 2002).

Romanow also offers little comfort to Canadians concerned with the issue of privacy in an electronic age. It is a basic premise of all privacy law and legislation that individuals must give consent before others are allowed access to their confidential information. This is especially so when dealing with personal health information. However, in dealing with the issue of electronic health records, the most dangerous area for breach of privacy, Romanow misses the mark. He states “privacy rules have to strike the right balance between strict privacy protection procedures and the legitimate and important need for health care providers to access personal health information, often on an urgent or emergency basis” (Romanow, 2002). (emphasis added)

The Alberta Government was quick to accept this open invitation from Mr. Romanow. In February 2003, Bill 10 was introduced in the Alberta Legislature. It repeals s.59 of the Health Information Act and thereby removes the requirement to get patient consent before information can be shared through electronic means. In a triumph of expediency over principle Health Minister Gary Mar was reported to have said in an interview “getting consent is administratively difficult,… and it’s not an essential part of patient confidentiality”(Ruttan, 2003).

The Romanow report engages in rhetoric founded on social and political ideology. It relies on instrumental values like equity, fairness and solidarity, which are meant to accomplish an intended purpose or result. Fairness depends on where you are standing. True core values like truth, honesty and integrity are common, or should be, to all endeavours and purposes. The Romanow report is a negative factor in advancing the debate over much needed health care reform in this country.

The problem of basing a proposal, platform or policy agenda on values is that someone might examine them, especially if they are called “shared values”. Wayne
Norman, who teaches political philosophy at UBC, reminds us that the “one thing all the parties’ lists of values have in common is vagueness”. This raises many dilemmas for those who preach the ideology of shared values. Norman explains that “[on] the one hand, if we interpret any of these value commitments more precisely – for example by specifying what exactly is meant by “equality”(Romanow uses the values of equity, fairness and solidarity) – then it will not be true that all Canadians cherish that particular value… On the other hand, if one interprets these lists of typical “Canadian values” broadly enough so that almost all Canadians do share them, then it will also be the case that almost all citizens in other democracies do as well”. Norman also notes that “it is now painfully clear that talk about shared Canadian values can sell a lot of beer, but can it really save a healthcare system, or keep a country from breaking up?” (Norman, 2000).

Romanow exploits the Canadian need to compare and contrast ourselves with the United States as part of our values assessment. Romanow, under the heading “Private For-Profit Services Delivery: The Debate”, focuses Canadians on the United States as follows: “Proponents of for-profit care may insist that the quality of care is not an issue, but there is evidence from the United States to suggest that the non-profit sector tends to have better quality outcomes than the for-profit sector in such things as nursing home care and managed care organizations and hospitals…For those reasons, the Commission believes a line should be drawn between ancillary and direct health care services and that direct health care services should be delivered in public and not-for-profit health care facilities” (Romanow, 2002).

This tunnel vision allows politicians, policymakers, and opinion shapers to portray anything that appears to be the opposite of “American values” as good. The result is that any policy with the “Canadian values” label is good and everything else is bad.

Canadian values are also routinely packaged in the flag of tolerance and compassion. Canadians are slowly being conditioned to believe that they should be prepared to tolerate almost anything. After all, we are supposed to be a kinder and gentler nation. This juxtaposition of the so-called Canadian values of medicare with the United States again emphasizes our abiding Canadian value of constant comparison with the United States. But why do we or should we compare our values and policies only with those of the United States. Why do we need to compare our 30th ranked second-rate health care system with their 38th ranked third-rate health care system?

To disagree with any part of the Romanow Report is now to be seen as intolerant, and to embrace ugly American values. This is no way to reform a health care system let alone a country. It’s why Chistie Blatchford of the National Post recoiled at the Romanow Report and stated “I do not accept that either I or my country is defined by medicare. I especially refuse to accept that we are defined by a mediocre medicare.” Ms. Blatchford found her Canadian values elsewhere. She stated “I am personally defined as a Canadian first by the national game and by the thousands of our hockey rinks” (Blatchford, 2002). Ms. Blatchford may be close to the truth by intuitively relying on a national game and a national landscape.

An Environics poll of October 17, 2002 noted that “fewer than half of respondents would support increasing taxes to pay for health reforms. But notably, only 10% of Canadians would accept a health care system that excluded those who could not afford to pay for services. ” According to Brian Lee Crowley, President of the Atlantic Institute for Market Studies, these results need not be seen as a contradiction because as stated by Jane Armstrong, senior vice president of Environics, Canadians are “ever-constant champions of fair play and equity” (Crowley, 2002).

Furthermore, a Strategic Counsel poll of December 2002 examined Canadians’ views on the health care system and noted that “nationally, 70% said the problems stem from poor management and waste, while only 25% said it was from inadequate funding.” And that “accountability is a tremendously important issue for Canadians” (Kennedy, 2002). The focus of accountability in the Romanow Report is on provincial governments. In this it misses service providers, hospitals, health authorities, unions, and Canadians themselves as taxpayers, patients and informed consumers of health products and services.

In the absence of accountable or inspired leadership, Canadians must, as informed consumers of health care and as eventual patients or residents, critically examine each and every prescription for health care reform. We must be on our guard when the prescription is packaged in the cloth of values. We must distinguish between the solution and the snake oil. We must be mindful of any treatment’s efficacy, as well as its aversive, harmful or interactive effect. In short we must use our minds and our souls and not our egos and our hearts. I believe if we do, we will find much of value in Kirby, Clair, Mazankowski and Fyke. They collectively contain the elements of fundamental and meaningful health care reform.

References

Blatchford, C. (2002, November 30) I won’t be defined by mediocre medicare. National Post

Commission on the Future of Health Care in Canada. (2002). Building on Values: The Future of Health Care in Canada – Final Report.(Romanow Report). Government of Canada http://www.healthcarecommission.ca/Suite247/Common/GetMedia_WO.asp?MediaID=1162&Filename=HCC_Final_Report.pdf

Commission on Medicare (2001). Caring for Medicare:, Sustaining a Quality System. (Fyke Report). Government of Saskatchewan http://www.health.gov.sk.ca/info_center_pub_commission_on_medicare-bw.pdf

Crowley, B.L. (2002, December) The Top Ten Things People Believe About Canadian Health Care, But Shouldn’t. Atlantic Institute for Market Studies (AIMS) http://www.aims.ca

Kennedy, M. (2002, December 30) Wasteful spending may have created problems poll finds. Edmonton Journal

Murphy, R. (2002, November 29). Point of View - The National [Television broadcast] Toronto: Canadian Broadcasting Corporation.

Norman, W. (2000, June 24) Shared values do not a country make. National Post

Premier’s Advisory Council on Health. (2001) A Framework for Reform (Mazankowski Report). Government of Alberta http://www.gov.ab.ca/home/health_first/documents/PACH_report.pdf

Quebec Commission on the Study of Health and Social Services. (2000) Emergent Solutions (Clair Commission). Government of Quebec. http://www.cessss.gouv.qc.ca/pdf/en/01-109-01a.pdf

Ruttan, S. (2003, February 26) Bill puts onus on patients to ensure records private. Edmonton Journal, p. B5

Spector, N. (2002, December 20). Federal screw-ups a legacy of power. Edmonton Journal

Standing Senate Committee on Social Affairs, Science and Technology (2002). The Health of Canadians – The Federal Role. Final report (Volume 6): Recommendations for Reform (Kirby Committee) Government of Canada
http://www.parl.gc.ca/37/2/parlbus/commbus/senate/com-e/soci-e/rep-e/repoct02vol6-e.pdf