Problematic principles: the CMA on public/private health care.

• Author: Downie, Jocelyn
• Position: Canadian Medical Association

In June 2006, the Canadian Medical Association [CMA] published a discussion paper, "It's about access! Informing the debate on public and private health care," to evaluate how best to manage the public and private health care sectors in order to improve access to high-quality health care. (1) The report comes at a critical time for the health care system in Canada, with talk of renewal and reform at the forefront of public discussion. In their report, the CMA "identified 10 first-order policy principles that should guide any policy and decision-making related to the public-private interface." (2) The CMA's use of these principles is problematic on four levels.

First, the principles embraced by the CMA, as they are defined in the report, should not be considered "first-order." The Oxford English Dictionary defines a "first principle" as "a primary proposition, considered self-evident, upon which further reasoning or belief is based." (3) But how can one have ten "primary" propositions? The CMA's misunderstanding of a first-order principle can be illustrated further by examining one of its listed principles: choice. The CMA defines "choice" as patients having a choice of physician and physicians having a choice of practice environment. (4) However, this principle, as defined, should not be considered first-order. As noted by Beauchamp and Childress in their leading bioethics text, choice is a tool for respecting autonomy and is therefore, a "mid level" principle subsidiary to the higher order principle of respect for autonomy. (5) In a specifically Canadian context, one can refer to the National Forum on Health report which identified the health care values that are held by Canadians. One of the values was "dignity and respect," defined in terms of treating individuals with dignity and respecting their innate self-worth, intelligence and capacity of choice. (6) Again, choice is considered a secondary principle, in this case, grounded in dignity and respect. Viewed in this way, choice must be defined in a way that respects the dignity of all Canadians. However, because the CMA failed to appropriately define its first-order principles, it has defined choice in a way that could jeopardize the accessibility of quality health care for the more vulnerable members of society and, thus, threaten their dignity.

Second, the CMA provides no justification for the selection of its principles. Perhaps the principles could have been justified by reference...