|The University of British Columbia, Green College, May 7-8, 1999
Nichola Hall and Audrey Gill
Catherine Aczel Boivie (Chair)
CIPA-West thanks the following sponsors for their generous support of our first conference:
- Continuing Studies, University of British Columbia
- Catherine Aczel Boivie
- Peter Eng
- Rebound Consluting, Ltd.
And thanks these additional sponsors for helping to establish this public affairs forum in Vancouver:
- The Glen Ardith-Frazer Corp.
- Great Pacific Management Co. Ltd.
The mission of the Couchiching Institute on Public Affairs, Canadas oldest public affairs forum, is to increase the awareness and understanding of domestic and international issues among people in Canada, through open and inclusive discussion, without advocacy or partisanship.
Although the Western chapter was just founded in 1998, the Institute was created in 1932 and has held a conference in August every year since. Current and former world leaders who have participated credit the experience with helping them cultivate their own opinions.
Membership fees cover costs of keeping members abreast of the Institutes activities. Event fees are kept reasonable to encourage wide participation. Individual, corporate and government support are all crucial to the continued existence of the Institute.
For more information about CIPA-West, please contact Judy Waller at (604)904-5777
Table of Contents
Michael Walker, The Fraser Institute
Michael Goldberg, Social Planning and Research Council
Dr. Kathryn Harrison, Environment
Paul Gallagher, Education
Dr. Charles Wright, Healthcare
Robin Hanvelt, Social Policy
Speaker and Panelist Profiles
Individual Rights and Societys Responsibilities:
Striking the Balance
A forum to examine and debate these values which underlie the organization of our society.
The first CIPA -West conference included two main events: a debate between Michael Walker, of The Fraser Institute and Michael Goldberg, of the Social Planning Research Council; and a Panel Discussion moderated by Darlene Marzari, Former MLA and Minister of Municipal Affairs, with panelists representing perspectives from the education, social policy, environment and healthcare sectors. All present participated in a lively discussion from the floor, and later in small groups.
Mr. Walker distinguishes between negative rights (or what he calls "freedom from" rights) and positive rights (or "freedom to" rights). Since positive rights require someone else to provide resources so that the individual can enjoy the right, the only universal rights we should really talk about are the negative rights. For him, the real topic of this conference is the relationship between the roles of individuals and the role of the government, or state.
Mr. Goldberg said that to him, embedded in the conference title is the concept of "individual autonomy versus freedom and desire to create society." He explained that the concept of "society" is one created by individuals by their own choice. And society is more than the sum of its parts. Most individuals, according to Mr. Goldberg, want some autonomy and some choices. And choices are constrained by the political, economic, and social realities of the time, as well as limits on resources. Mr. Goldberg says that four values should guide us in making these decisions about how we allocate these limited resources: equity, security, citizenship and democracy. These four values, he says, can help us to judge whether particular policies have value.
Darlene Marzari explained that the purpose of this session was to provide an enriched notion of what the continuum of individual rights and social responsibility looks like and where we sit on it. The four panelists each presented a different perspective from their own area of expertise.
Dr. Kathryn Harrison talked about the environment, pointing out that every day we make choices choices that represent personal self-interest and that sacrifice our collective well-being. We face, she says, the challenge of balancing individual rights and collective welfare; the well-being of humankind and other living creatures; and, the well-being of those living now, with those who will have to live in the future. If we cant get the balance right on the first question, the other two will likely be discouraging. Dr. Harrison concluded that "the invisible hand just isnt working anymore." Governments have two very different choices: one is regulation, and the other persuasion. We must all recognize that if we continue to make narrow self-interest decisions, it will not be sustainable in the long term at the collective level.
Paul Gallagher represented the education perspective. He said that although historically the education training, and learning systems have served Canadian society and individuals well, it is time for change. Over the past 10 years weve moved from a predominantly industrial economy to one driven by knowledge and technology. Mr. Gallagher suggests that we need a new balance between individual rights and social responsibility, and that this new balance must include considerations of fairness, compromise, peace, order and good government. We need to think of the "universe of education" not just each one (pre-school, elementary, secondary, post-secondary) separately, converting Canada from an education society to a learning society. We should eliminate the demand for private schooling and the existence of the notion of "education for the best, training for the rest." Making it happen will not be easy. Mr. Gallagher notes that we have the resources, but he questions whether we have the political will to do it.
Dr. Charles Wright presented the view from the healthcare perspective. He questioned whether, when it comes to healthcare, the topic is "individual rights and society responsibilities," or "individual rights and society rights"? Sometimes the two match, and sometimes they do not. The question, he says, is of equity of access to necessary medical service. Dr. Wright observes that some say the Canadian healthcare system is falling apart. But, he claims, it is a question of need versus demand, and of necessary treatment versus voluntary, or optional treatment. Yet in the immediate term the solution is in making choices and making those choices explicit rather than implicit. Dr. Wright suggested that we need to stop thinking of rationing as a dirty word, and set up a major level task force to look at the issues of priorities and to define boundaries of necessary medical services.
Mr. Robin Hanvelt presented the social policy perspective. For him the principle of leaving individuals to their own choices is only appropriate if the benefits and consequences are borne by the individual. If consequences are not, then individuals will do much more than they normally would (stretch the rules). If the benefits are not, they wont do enough. And, if the hard work exceeds the benefits, then they will likely not do it at all. Mr. Hanvelt acknowledged that when we make decisions, it is almost impossible to do "just one thing" there are always unintended results. Mr. Hanvelt claims that weve been acting in the wrong way. We need to think about society as a whole and the impact it has on individuals. If you understand the causality, he adds, you can think about the bigger picture and make decisions appropriately based on the total burden that will result. The causal problems need to be addressed in order to come up with relevant long term solutions.
Nichola Hall, Coordinator of Community Programs in the Continuing Studies faculty at UBC, and Conference Co-Chair, welcomed participants to the event. She explained that CIPA-West was established about eighteen months ago and was launched through a series of roundtable discussions. This event is the first in what is hoped to be an annual Couchiching-West conference series.
She explained that the purpose of all CIPA events is to provide educational forums for discussing international and national interests relevant to Canada. The goal is to provide Canadians with an opportunity to discuss with experts and with others, the key topics relevant to them. This event, Individual Rights and Societys Responsibilities: Striking the Balance, is a forum to examine and debate these values which underlie the organization of our society.
Ms. Hall also announced CIPAs annual conference this year, the 68th gathering at Lake Couchiching in Ontario (from August 5 8). The topic of the conference will be Science, Ethics and Human Destiny. This event has been described as summer camp for the mind, and Ms. Hall encouraged attendees to consider participating this year.
Turning her focus back to this event, Ms. Hall acknowledged that we are lucky to have the participation and support of the speakers at this conference. She thanked them for their contribution and encouraged the participants to enjoy the debate and panel presentations, and to participate actively throughout the next two days.
||Kevin Evans, Journalist and broadcaster, former CBC TV Vancouver news anchor
||Michael Goldberg, Social Planning and Research Council
||Michael Walker, The Fraser Institute
Kevin Evans introduced the debate session and welcomed participants to the forum and said that although many of us dont know each other, there is a community of spirit at this event. He added that although conventional wisdom says that we should all be home "cocooning" on a Friday night, weve all decided to be here to listen to these speakers debate and "cross swords."
Mr. Evans also acknowledged that attendees at this event are involved somewhat in "making history", since this is the first CIPA-West conference and he encouraged participants to "harness the intellectual energy" of the event.
Michael Walker, The Fraser Institute
Mr. Walker began his provocative discussion by referring to the forum title and saying that it is meaningless to talk about "society" having anything. He said that society cant have rights or responsibility because it cant be held responsible. Only individuals can be held responsible. Once you articulate those rights of individuals, then you can draw the line between the rights of the individual, and the rights of the collective of all individuals which is what, he says, we mistakenly call "society."
So, he asks, What are the rights of individuals?
Mr. Walker identified two categories of rights: negative, or what he calls, "freedom from" rights; and positive rights, or "freedom to" rights.
The characteristic of negative rights is that the exercise of them by one does not make it more difficult or less possible for any other individual to enjoy that right. In other words, negative rights are "universal rights." Every human being can claim access to them.
However, he says, it is positive rights we hear more about today. And it is these positive rights that require that someone else provide resources to allow the individual to enjoy the right (right to housing, right to healthcare, right to education, right to own a small business, etc.). This requirement for resources means that positive rights are not universal.
This is where there are practical consequences when we start to compare Canada to other jurisdictions. Mr. Walker explained that since Canada considers its boundaries for individual rights to be at its borders, there is an obvious conflict that arises in interpreting the premise of those rights. If we truly believe in these rights as universal, then we should not consider borders, or anything else as boundaries in our support and provision of those rights. Yet this is not the view we hold, and therefore the only universal rights we should really be talking about are the negative rights.
Having said that, he asks again, What are the rights of individuals? His answer is simple: "To respect the rights of others full stop!" With that framework we can now talk about what he feels the real topic of the forum is, the relationship between the roles of individuals and the role of the government, or state. This can be discussed in the context of two kinds of questions:
- What are the limits on private actions?
- What are the legitimate roles of government?
Mr. Walker said that there are three roles of the sovereign state:
- To maintain the system of laws;
- To protect against violation of those laws;
- To undertake those public works that would be difficult for individuals to take on themselves.
These enhance the ability of the individual to be free. And, these three roles are the reason people get together in communities and societies. The confusion or conflict, Mr. Walker says, comes from deciding what actions fit into the last point above. Where there is unanimous agreement, there is no problem. But there are many issues that do not have unanimous support. Different populations and groups will have different attitudes towards this.
Mr. Walker closed his presentation by saying that we used to think that we needed government to take on the common "public works" projects described above. Years ago, technology didnt exist to facilitate alternative approaches. Now, though, technology allows us to do much more than we used to be able to as individuals. Because of the advances in technology (and not just computer technology), some things that used to be feasible or practical to be done only by the government, can now reasonably be addressed by the private sector.
Michael Goldberg, Social Planning and Research Council
Mr. Goldberg promised to present a very different viewpoint. He said that he feels honoured to be one of the speakers here, and that the topic of the forum is one that anyone of us could take on there are, he said, so many different angles we could take in discussing it.
He added that embedded in the conference title is the concept of "individual autonomy versus freedom and desire to create society." He explained that the concept of "society" is one created by individuals by their own choice and that individual choice is the preeminent good. But, society places restrictions on individuals. Those restrictions are based on the overarching good and creating a society that promotes all people to maximize their abilities. Society, therefore, becomes the enabler.
Society, observes Mr. Goldberg, is more than the sum of its parts. It requires relationships of mutual interdependence. And, that identity can only be confirmed if others can also recognize our value. Therefore, society is really based on mutual recognition and interdependence of values.
Most individuals want some autonomy and some choices. And, most of us want self-determination our own perception of what is the "good life", our own sense of identity.
Choices, however, are constrained by the political, economic, and social realities of the time. At any one moment in time, there are limits on resources. So the question that Mr. Goldberg raises is: how do we make decisions about the allocation of these limited resources?
He says that there are four values that should guide us in making these decisions:
- Citizenship and
These four values can help us to judge whether particular policies have value.
Mr. Walker acknowledged that Mr. Goldberg had said that we create societies to do certain things. However, he argued, we do not create societies, we create governance, institutions, systems not societies. Society, he says, is the by-product that results from creating the governance, institutions and systems. He cautioned that it is important to pay attention to the kinds of institutions we create because these form incentives for behaviour. Behaviours that we see are a direct result of the institutions and incentives we create. It is possible to change societal outcomes by changing incentives.
The next point he discussed in rebuttal was that of "social collectiveness." Such collectiveness arises out of voluntary action, out of individual action. Societies exist based on the belief in the system of negative rights and individual autonomy, which are perfectly compatible with collectiveness and cooperation.
Mr. Walker proposed that the market is the most effective system to get people to work together. Markets are enormous systems of cooperation. The market is the incentive.
Mr. Walker also discussed the notion of equity that Mr. Goldberg had introduced. He said that the one problem with the notion of equity is that before you can distribute anything, you have to have it. And, even once you have it, the system under which it will be distributed will influence how it will be produced. So, you cant talk about distribution without talking about production of resources.
Mr. Goldberg acknowledged that the participants had heard two very different views.
He said that all the institutions that we have came from somewhere. And, he claims, they came out of the struggle of individuals coming together collectively to overcome imbalance of power and wealth.
Mr. Goldberg referred to Mr. Walkers statement that the self-interest of individuals will lead to social good. But, Mr. Goldberg argued, that system has been tried and failed.
Question 1: Regarding the market as a process of cooperation, how do you distinguish between cooperation and exploitation?
Mr. Walker said that when we talk about exploitation of resources and labour in other countries, we have to be very careful to understand the context under which they are at work. One of the "great freedoms people have is to be exploited." Individuals must recognize that by making an investment in capital and in your community, organizations can make a profit. So, individuals must consider what they have to offer if they are going to improve their circumstances.
He used an example of child labour in one country The Fraser Institute studied. It was found that children were better off working than they would have been with any other option that was open to them. He said that we cant apply a standard of morality that we wouldnt apply to ourselves - we just cant impose our rules on their societies. In fact, he says, their societies need the capacity to enforce and live by the laws that exist and if this capacity does not exist, then the laws are meaningless and unsupported.
We have to consider: what otherwise would be the case? Mr. Walker said that these countries have to go through the same steps of development that we did in North America.
Mr. Goldberg responded that we did go through the same things and although Mr. Walker claims that it was the capital market that caused change that was not the case. Rather, it was out of people coming together to say "enough."
All of the gains were not out of the munificence of the capital market, says Mr. Goldberg, but from people. Capital does not make decisions, people with capital make decisions and people without wealth come together to form communities of common interest.
Question 2: We see the international flow of capital and the differences that exist between young and old countries. Could you comment on whether some of the alternative approaches in places like Bangladesh and other countries, regarding "micro loans" and educating grants, have better merit than capital exploitation.
Mr. Walker acknowledged that of course there are alternatives and it is the individuals right to choose the approach. If you give people economic freedom, they will find ways to move forward.
He said that the equation of capital plus technology plus education results in productivity. But, all of these components of the equation cost money. Freedom does not cost anything. The most important thing, according to Mr. Walker, is to create freedom so that other aid can be used effectively and productively. Until those countries are stable enough with environments predictable enough to move forward, then nothing we impose upon them will be of benefit.
Mr. Goldberg responded that perhaps it is possible for us to learn from history and to not force others to repeat every aspect of that history in their own development. Perhaps we could leave part of the risk of the path behind. Yes, he admits, some learning comes through living through the steps, but other changes can occur without such learning.
Question 3: There is both exploitation and a degree of democracy in existence. Yet, it also appears that there is a new recognition as a society of "social conscience" for organizations. Could you comment on this notion of "capitalism with a human face."
Mr. Goldberg acknowledged that corporations have a role to play. They always have - the language to describe that role has changed, but the role has always existed. Some organizations play their role well, and others dont. And, part of whether it happens or not, depends on how it is constrained. He says it is based on what we, as members of the community and the country, consider to be acceptable.
The bigger fear is that control of corporations is falling into fewer and fewer hands. According to capitalist theory, anyone can enter the market and compete. However in practice, concentration is into a smaller and smaller number of hands, which limits freedom of the individual. He asked: how do you constrain this power? The answer is by regulation. And, in the long term such constraints will be imposed by what he calls "world people" not "nation state people."
Mr. Walker responded that the notion of corporations having a social conscience is an interesting one. He says that if a corporation has enough power to be concerned about anything more than maximizing the value to the shareholders, theres something wrong.
||Darlene Marzari, Former MLA and Minister of Municipal Affairs
||Paul Gallagher, Education
||Robin Hanvelt, Social Policy
||Kathryn Harrison, Environment
||Dr. Charles Wright, Healthcare
Audrey Gill introduced the panel session. She said that we are in a bit of a conundrum with the topic of this conference. On the one hand, we can totally agree with one speaker and then five minutes later, we find ourselves totally agreeing with the other saying something totally different.
Yet, this is the intent of this conference to provide us all with the time to reflect and think and discuss the various points of views.
Darlene Marzari set the tone of the panel discussion in saying that we could consider the topic to be "individual rights and social responsibility" or "social rights and individual responsibility." She said that almost every decision we make in public life, personal life, or any institution is made in the context of these balances. The issues that relate to this balance come up every day, everywhere. The point of this session is to provide an enriched notion of what the continuum looks like and where we sit on it.
Dr. Kathryn Harrison, Environment
Dr. Harrison started her session by asking participants how many people drove to the event, and how many drove alone? She said she didnt ask the question as a means of making people feel guilty. Rather, the fact that so many people answered "yes" is a stark illustration of why we attended the event to discuss the conference theme.
She said that every day we make choices choices that represent personal self-interest and that sacrifice our collective well-being. And this is the basis of the tension that exists between individual rights and social well-being.
Dr. Harrison explained that there are three environmental questions that exist in relation to the conference theme:
- the one discussed above about balancing individual rights and collective welfare;
- the question of how to balance the well-being of humankind and other living creatures;
- the question of balancing the well-being of those living now, with those who will have to live in the future.
If we cant get the balance right on the first question, the other two will likely be discouraging.
Dr. Harrison explained that in the world of economics, the theory goes that self-interested behaviour has the fortuitous benefit of resulting in collective well-being (collective aggregate welfare). This is true in a "perfectly competitive market", where transactions are voluntary, with each party pursuing their own self-interest. However, she observes, "all bets are off" when others, outside the two parties involved directly in the transaction, are affected without voluntary participation. And, it is because of this reality that weve entered into a realm where individual self-interest is in tension with the collective well-being. History has shown that when the common good resources are left unregulated, problems result.
Dr. Harrison asked a second question: How many people think government should do better at environmental protection, yet how many of us participate in environmental groups?
Dr. Harrison described one of the issues that arises with regards to such participation is what is known as the "free rider problem." This is where an environmental group, or other interest group, lobbies for some common good, and others receive the benefit of their efforts without having to participate. She said that demands on our time and our priorities lead us to the temptation of the free-ride.
The obvious conclusion, she says, is that "the invisible hand just isnt working anymore." By virtue of the fact that we share the universe, individual self-interest results in damage to the collective good. So, how do we proceed?
Dr. Harrison acknowledged that there are two very different choices for governments, predicated on two very different views of human nature. One is regulation, and the other is on a more persuasive approach to influence choices. She described some examples of such persuasive approaches, including eco-labelling and the aim for ISO 14001 certification.
Dr. Harrison said that she assumes that we all recognize that if we all continue to make narrow self-interest decisions, it will not be sustainable in the long term at the collective level. She observed that governments today are somewhat schizophrenic in that they dont know which view of human nature is right. Regulation has worked in the past, but as the size of organizations decreases and the number increases, it makes regulation harder. We know very little about the results of non-regulatory programs mostly due to a lack of credible measuring instruments and because of poorly defined initial goals of the programs.
Dr. Harrison concluded her presentation by saying that she has no simple answers to offer. On the one hand, we keep making choices of self-interest, either selfishly or just because of lack of knowledge or lack of thinking. On the other hand, elected governments can only tax and regulate so much until they face the requirement of re-election. And, it is the acceptance of their policies that leads to re-election. To illustrate this, she asked the question, "If we dont ride the bus voluntarily, will we be willing to elect a government that regulates us to ride the bus?"
Paul Gallagher, Education
Referring to Dr. Harrisons closing comments, Mr. Gallagher said that he hopes in the area of education we will have solutions, but he warns, they wont be simple. The conference topic was timely in all areas, and particularly in the area of education.
Mr. Gallagher advocated that a shift in balance must take place as the circumstances of our times change.
To illustrate some of the tensions in the field of education, Mr. Gallagher reported that Canadians have been known to universally accept the notion of public education for K-12. Yet we also support publicly-supported independent schools and home schooling, publicly-subsidized post-secondary education, and we provide public support to those who choose to get their educations elsewhere (outside Canada).
Mr. Gallagher concluded that historically, the education training, and learning systems have served Canadian society and individuals well. How good has the product been? He says that providers have done what we have asked them to do to prepare us. And Canada has a highly educated, highly trained, talented workforce. We have work and economic independence for all but the least skilled, and we have a safety net for those dislocated from the workforce. He acknowledges that weve had all that, but that it hasnt been equally distributed and he contends that weve been working on this imbalance.
Over the past 10 years weve moved from a predominantly industrial economy to one driven by knowledge and technology. Therefore, we need new imperatives for education and learning. He presented the following as some of these imperatives:
- the ability to compete internationally is critical to our well-being;
- knowledge is opportunity: it is imperative that if we are going to have opportunity for all, then there has to be access to knowledge for all as he says, "to know, and to know how"
So what are the options for moving forward? They include:
- Continue to modify, refine and tinker with the educational system (thats whats going on now, he says);
- Commit to the "status quo" (do nothing);
- Replace or transform the systems and structures to better align them to the knowledge-based, globally oriented, more equitable opportunity-based world.
Mr. Gallagher says that we need a new balance between individual rights and social responsibility because the circumstances have changed since the system and structures were designed. This new balance must include consideration of fairness, compromise, peace, order and good government.
What would this new balance look like, Mr. Gallagher asks? In the past we have thought about pre-school, primary school, post-secondary school, graduate education as separate things. What needs to be done is to think of the "universe of education" not just each one separately. We need to convert Canada from an education society to a learning society. This will require some changes, according to Mr. Gallagher.
First, we need a huge, heavy investment in preschool years. Studies have shown that this is the right time to invest in learning. Additionally, we need a much more decentralized set of learning opportunities for children in the 6-16 age group, with far more options than now. We need to eliminate the demand for private schooling and the existence of the notion of "education for the best, training for the rest." Change is also required in the choices for those in the grade 11/12 range. For example, one idea Mr. Gallagher advocates is that every student who completes 10 years of education should get two years free training, whenever they choose to use it in the future.
To make this work, Mr. Gallagher proposes that funding should follow the student, not the institution. We need to see, and find the way, to make it possible for virtually everyone to have a sound education.
If we say that upgrading of skills of the workforce is necessary, then who should pay? Mr. Gallaghers answer is, that employers should pay to some extent, as should those who want to be upgraded. Those who have been displaced from the workforce and want back in should be addressed by the public system.
Mr. Gallagher says that it is time to produce a new balance for the new circumstances for the age in which we live, but more importantly, for the age the younger generations will live in. Can it happen? We have the resources, but he questions whether we have the political will to do it.
Dr. Charles Wright, Healthcare
Dr. Wright described the conference theme as a fascinating topic. He questioned whether, when it comes to healthcare, the topic is individual rights and society responsibilities, or individual rights and societys rights? He says, sometimes the two match, and sometimes they do not match.
Where they match is that Canadians have expressly articulated values of our healthcare system. The question is of equity of access to necessary medical service. In most civilized countries, some provision is made for required medical services. We have collectively, and he adds, correctly, taken the right approach.
Dr. Wright says that there is only one standard that meets both individual rights and societys responsibility. And, here in Canada, our system is the best available in the world. Who of us would agree to less in terms of skills, training, and safety of our medical system? But we must ask: what constitutes a necessary medical service?
According to Dr. Wright, we have long since left behind debate of providing necessary medical services. But now, we are debating what are "necessary medical services." We are debating quality of life services such as cataract treatment, arthritis treatment, heart surgery that some years ago didnt exist. And, this is part of the perceived problems with our healthcare system. Medicare was defined and set up in an era when these high volume, high ticket services were not available. But who now defines whether they are necessary medical services? This is why we have come to what he calls a point of inevitable conflict.
Dr. Wright observes that some say the Canadian healthcare system is falling apart. But, he claims, it is a question of need versus demand, and of necessary treatment versus voluntary, or optional treatment.
As individuals, Dr. Wright advocates, we also exist under the "rule of rescue" the notion that we would not let another individual suffer if we could help when they were in critical trouble. Yet, we also believe in the need for insurance. If we make insurance mandatory, then should everything be covered? And, if everything isnt covered, then who would insure against what? Would the average person insure against certain types of cancer, if they werent predisposed to that illness? And then what would happen if they did contract the disease and were not insured?
In another light, though, Dr. Wright asks, What about peoples personal responsibility for their own health? When we consider this aspect, we come up against ethical questions such as, Should we do heart bypass surgery on someone who continues to smoke?
So, he says, he thinks the question is futile. And, he offered what some might consider a somewhat sinister idea that of rationing services. We seem to have decided in society that individual rights overwhelmingly take precedence over societys rights in terms of healthcare. And, although we know what the determinants of health are (we know what makes healthy people e.g., good housing, sufficient food), we continue to ignore them.
On a positive note, says Dr. Wright, fortunately we have managed to deal with lots of these things in the past. The cost-effectiveness issues are a real struggle and, were not good at making relative decisions in relation to the effect the decisions produce (cost and allocation of resources). One of the reasons for the misguided focus, according to Dr. Wright, is that doctors deal with each patient, one at a time they dont look at the "big picture." He suggests that health economics are starting to get more attention. The problem with what we are doing in healthcare today will be a problem for the species as a whole.
We are treating diseases now where people are surviving what they could never before survive. This is where our current system is being burdened and challenged. And, because these services are available, that makes them covered under our medical plan, even though the plan was not originally designed to include such services.
In terms of offering solutions, Dr. Wright said that he did not have any for the longer term. But for the immediate term, the solution is in making choices and making those choices explicit rather than implicit. He suggested that what is needed is a major level task force to look at the issues of priorities and to define boundaries of necessary medical services. We need to stop thinking of rationing as a dirty word.
Robin Hanvelt, Social Policy
Mr. Hanvelt opened his presentation with a quote from the Canadian Charter of Rights and Freedoms:
"The Canadian Charter of Rights and Freedoms guarantees the rights and freedoms set out in it subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society."
Mr. Hanvelt said he would offer a framework for judging interventions in terms of social policy, drawing on the legal system. When a law is challenged, there are a number of tests that must be considered:
- A rational connection between the legislation and the objectives;
- Impose minimum burden (cost-effectiveness most for the least);
- On balance, need to do more good than harm.
Mr. Hanvelt acknowledged that when we make decisions, it is almost impossible to do "just one thing" there are always unintended results and this could lead to creating or enhancing a secondary problem when we make a decision.
In terms of social policy, Mr. Hanvelt says, the principle of leaving individuals to their own choices is only appropriate if the benefits and consequences are borne by the individual. If consequences are not, then they will do much more than they normally would (stretch the rules). If the benefits are not, they wont do enough. And, if the hard work exceeds the benefits, then they will likely not do it at all. Additionally, the notion of leaving everything to individual decisions assumes consequences are independent. Yet, they are not. Therefore, this is where intervention is needed.
One of Mr. Hanvelts key ideas is that we need to "go up river" to figure out the "why" of our problems and then stop/fix the problem, instead of just reacting to the symptom.
But this kind of approach requires us to think about the information we need regarding causal effects so we can make choices. It means we should all know about intended and unintended results.
The question becomes, according to Mr. Hanvelt, where to do intervention and when instead of waiting for the event. And, this leads to the question of when do we have to work together to deal with the underlying problem. Yet, each player will have a different perspective on the problem, and this adds complication to defining the approach required.
Mr. Hanvelt says that one of the problems with our decision making processes is that we are not good at dealing with uncertainty in our decisions. As an example, in the social work industry, most child care services are administered on a voluntary basis. And, most work out OK. Yet, the few times where a decision is made that turns out not to be the "right" decision, we blame the social worker and the system, instead of acknowledging the role of uncertainty, and the need to look at the bigger picture (more good than harm). Mr. Hanvelt says that we need to acknowledge that in situations with uncertainty and lack of information, errors will be made on both sides.
He says that we are starting to do more research and understand more about social policy. Not individual behaviour, but decisions that we make as a society, affect individuals lives and they dont have the power to change that. There is a reason to invest in the social environment because individuals cant change these things themselves.
Mr. Hanvelt claims that weve been acting in the wrong way. We need to think about society as a whole and the impact it has on individuals. If you understand the causality, you can think about the bigger picture and make decisions appropriately based on the total burden that will result. And, he concludes, the causal problem needs to be dealt with for long term solutions.
Question: What about the notion of some social healthcare and then the ability to "top up" with private healthcare? And, as a follow on to that, what does our proximity to the United States border have to do with our ability to make and implement choices?
Robin Hanvelt said that he agrees that the proximity to the U.S. border does represent some form of constraint on our choices for implementation. However, he says, we could still change from a criminal to non-criminal focus for certain drugs (legalizing certain drugs). He said it is important for us to think like a good economist for society for example, if we legalize drugs we take away the incentives for drug dealers, get rid of the black market, and eliminate the need for crime. We could then redirect resources to helping addicts with their health problems.
Question: Although the discussions have been very insightful and provocative, something is still missing. Do we require a new kind of political will? Based on earlier presentations by the panelists, even if we did have the knowledge, could we make the decisions without an ethical framework in which to make them and if so, what is that framework?
Kathleen Harrison responded that she agrees with the comment about having the knowledge but still not being able to make the right choices. She added that when it comes to considering the information required to make decisions, we have to ask:
- If it was available, would we access it?
- Even if we accessed it, would we make the right decisions?
She adds, there is no invisible hand were not ready yet to make all these decisions as individuals for the greater good.
Robin Hanvelt added that the big problem over the past 20-25 years is in terms of dismantling our government. We dont have the skills in our government to make major social change happen. We require a public debate on ethics reconciling different values. He explained that this was worth doing because we do have some of the right information to make decisions. The potential will be to start a respectful debate. Until then, he says, we will be delayed in "going up the river."
Paul Gallagher also responded saying that he has been impressed with the diversity in Canada. And, because of this diversity, it is difficult for him to imagine a common ethical framework ever existing. For him the key to success will be in valuing diversity of all kinds and respecting each other. If we think about the truth, we will realize that we have not educated people to make choices at all but instead, to live with the decisions others make for them.
Charles Wright quoted from a study conducted in the United Kingdom that stated that no country is able, nor will they ever be able, to provide every possible means of healthcare to all of their citizens on demand. The question then becomes: how do you define a societally acceptable rationing program for healthcare services? Dr. Wright acknowledges that one point of view says that there will not be any chance of gaining consensus on this issue, so we should just continue to ration services implicitly rather than try to make it explicit since that is a losing cause.
Robin Hanvelt concluded this discussion by saying that Canada pays a lot for healthcare. The United States pays 50% more yet we have come out better on all measures of success. Other countries that do even better than Canada, spend less, not more than we do on healthcare. Again, if we focus on spending our effort "upstream", on causes, rather than on results downstream, we can lower the overall cost of healthcare. He added that we know we can lower the rate, for example, of low birthweight babies, and we know we can do it right now. We have to take the action necessary to make it happen; yet we seem to be more willing to treat the problem than to prevent it.
Question: Perhaps we need to get to an even smaller core problem. When we talk about public debate, we need to get to the core, so results of public debates become higher priority of government. The participant wondered whether we really need to get down to evolving democracy as a priority in Canada. Is the real problem that we need to make our democratic process more democratic?
Paul Gallagher used an example of a report commissioned by North Vancouver City Council which wasnt ever discussed because of some threatening content. He said that changes wont happen by wanting the government to do it - they will only occur when the population at large says the government must do it, and when the population is educated to react in this way.
Question: I am opposed to full voluntary democracy. It is important to realize there will never be a consensus on "common good." Common good is based on values, and values are represented by political parties by organizing. I dont think we will ever have a time of consensus on the thinking about "common good" and if we did, it would be boring and not in line with human nature.
Robin Hanvelt emphasized that there are serious structural changes required in government and how it operates. Additionally, there is a need to educate the public on how it is supposed to work and the implications about that. He says that we have lost sight of the principles of government and politicians are getting away with it and were letting them do it.
Question: With regards to healthcare, please comment on the responsibility of the collective society to provide services, balanced with the right of the individual to buy services.
Charles Wright explained that it seems intuitively correct to consider that some healthcare services should be provided by society, and others should be left to the individual to purchase at their own will. However evidence shows that such a situation results in problems. First, there is some confusion about the concept of "equity" by Canadians (who has equal rights to what). The Canadian healthcare system is based on the notion that not everyone gets what they want, but they will get what they need. Second, he observes that two-tier systems do exist and they dont work. Such systems have proven to bleed resources from the public tier for the private tier.
Robin Hanvelt added that physicians in British Columbia have the right to operate in a mixed public and private manner, but they dont choose to do it because, he says, it doesnt work.
Question: I agree that education allows us to make decisions, but the alternate source of information for us to make decisions outside of our area of educational expertise, is the media. Please comment about the role of the media in providing such information.
Robin Hanvelt said that it is not just the press. Medical reports come out regularly, but they are controlled by drug companies who contribute funding for the research on which they are based, and therefore, may be biased. Reviewing the Web and talking with people like those on these panels, will allow individuals to hear all sides of a discussion and to formulate their own opinions.
Paul Gallagher responded by saying that we live in an increasingly technical world where background information is required to make decisions. Yet, even those at the high-end of education find it hard to get the required information to make the decisions. The local newspapers write to a very low education level, and therefore, will not provide the level of detail and technical information needed to make informed decisions. Part of the problem is also that individuals are not educated to make decisions based on the information they are provided.
Question: There are a range of value propositions to consider. Despite value differences, it is possible to come to agreement on certain solutions. Every one of the panel members seems to have been through processes that contribute to such common agreement so, could you comment on how those processes work so that we might learn from that?
Kathleen Harrison said that the right to say "no" sometimes bogs down the process of discussion and agreement formulation. She added that participants in a discussion and decision making process must understand that consensus is not always the best solution. She added to Mr. Gallaghers earlier comments that we need to educate students on how to make decisions.
Paul Gallagher said that we also must recognize the difference between technical decision-making, and public decision-making. To reach consensus on what is in the public interest, those involved must be willing to each give something. However, this process is not a good one for making technical decisions.
Charles Wright added that one process that does work, in spite of its bad reputation, is the Canadian healthcare system. 68% of Canadians support the values underlying the principles of the healthcare system in Canada.
Question: There is increasing discussion about sponsorship of what were previously public-owned and public-sponsored facilities (such as schools, parks, equipment). Please comment on what you think we are teaching people when we allow sponsorship into areas like the school system and other public institutions.
Kathleen Harrison observed that basic things (equipment and facilities) arent working in the schools, and that she would rather have sponsorship that allows her to work harder and better at delivering the education she is charged with delivering, than be constrained without sponsorship to work in an environment where the supplies and equipment are not available to do a decent job.
Paul Gallagher added that universities are firm in their image and level of integrity in terms of their own "branding" and yet they have managed to attract and work with sponsorship successfully. He believes that the depth and quality of research through universities has not been compromised by the sponsorship being provided.
Robin Hanvelt responded that in the short term, sponsorship is not a problem, but in the longer term it will be. We have become convinced that funding through the government is a waste of time (e.g., we talk about our tax "bill" but not our tax "benefits"). Consideration must be given to equity of distribution of resources. That is where governments come in to implement social policy and demonstrate the benefits. He added that government must sell the benefits of the social policies being implemented.
He also acknowledged that there are unintended consequences of short-term sponsorship. There are some people who dont think we should finance public activities and services, and yet, they are willing to finance commercial endeavours. As Canadians, we have to stop getting upset about paying for what we want.
Charles Wright said that what worries him about sponsorship is the ability of individuals to provide unbiased research. He said that it is against human nature to provide such results when they know where the funding for the research came from.
Question: We have talked about holding governments accountable, but in this world where corporations have more power than governments, why dont we hold corporations more accountable for their actions?
Kathleen Harrison responded by saying that when we do hold corporations responsible, it works. However, we just dont usually have the attention span to do it, and to stick to it. When consumers get their act together to organize and act, it is effective, but we shouldnt count on this as a way of holding organizations accountable.
Paul Gallagher added that we need to educate children to make choices. The younger generation have different values and will be much more eager in making changes than we have been.
Comment: One participant noted that the wording of Section 1 of the Charter (referred to earlier by Dr. Hanvelt) should be considered a success story. In one sentence it makes a pretty good stab at expressing the balance between individual rights and the responsibilities of society. She added that it is a pity that many individuals see taxes only as an imposition by society, and do not recognize the benefits they receive in exchange. Taxation and redistribution of wealth are in fact further examples of our attempt to strike the balance between individual rights and societys responsibilities.
Speaker and Panelist Profiles
(In alphabetical order)
Paul Gallagher is past president of three community colleges, and headed the B.C. Human Resource Development Project, a policy review of post secondary education (1991-93). He has served on provincial and national advisory bodies on international education, adult literacy, multiculturalism, access to post secondary education, to name a few.
Michael Goldberg is Research Director at the Social Planning and Research Council of B.C. With a BA in Economics and Masters in Social Work, he is a frequent media commentator and guest speaker on social, economic and fiscal policy issues.
Robin Hanvelt, PhD, teaches at the Centre for Health Services and Policy Research at UBC, and is an associate at Vancouver Hospital. He was formerly research manager at the Ministry of Social Services. Mr. Hanvelt is an economist whose research and social policy analysis cover social services, income distribution, health care and environment.
Kathryn Harrison, PhD, is Chair of Environmental Studies and Associate Professor of Political Science at UBC. Previously she was an environmental policy analyst for both Environment Canada and the Office of Technical Assessment of the U.S. Congress. She is the author of Passing the Buck: Federalism and Canadian Environmental Policy.
Michael Walker, PhD, is Executive Director of The Fraser Institute, a Vancouver-based economic think-tank. He is an economist, journalist, consultant and university lecturer. Mr. Walker has spoken across Canada and around the world, and has authored or edited over 40 books on economic topics.
Dr. Charles Wright is Director of Clinical Epidemiology and Evaluation Centre at Vancouver Hospital and Health Sciences Centre. He is a member of the B.C. Centre for Health Service Policy and Research and has a distinguished career in clinical and academic surgery. Dr. Wright is an outspoken commentator on healthcare policy.