Thursday, May 29, 2014

And what about what the woman wants? An Ottawa mother's story.

I post the following with the express permission of the mother involved. It is lengthy – but this mothers’ story needs to be told, in full.

A while ago – at the beginning of March, a Canadian mother-to-be in Ontario joined the Cesarean by Choice Awareness Network – at that time she was already 35 weeks pregnant. Her baby was transverse. She had a medical condition that limited her ability to push. She was also told she was ineligible for spinal anesthesia. This was her fifth and final pregnancy, her previous four had been low risk, relatively straight forward and fairly quick vaginal deliveries (note: a history of fast vaginal deliveries puts a woman at risk of precipitous labour). She had pre-existing PTSD from a car accident a year prior. She had a neurological condition which limited the amount of pushing that she would be capable of doing. She was considered a high-risk patient and up until that week, the care plan was for her to undergo a planned caesarean under a general anesthetic at term (39 weeks or more). Then, her doctor did a 180, for whatever reason – and informed the mother to be, that rather than a planned caesarean under a general, he wanted to perform an ECV (an External Cephalic Version) followed by an induction, trial of labour and an assisted (forceps or vacuum) second stage (pushing stage).

The mother wanted a planned cesarean.

I have to admit, that my mind was boggled at the scenario. It just seemed so ridiculous – I mean, I am used to the difficulty faced by women who want a caesarean because they see it as better meeting their needs and that of their family and do not have medical contra-indications to a planned vaginal delivery. That is generally why this blog, and the Cesarean by Choice Awareness Network exists. But this? Has the quest for vaginal birth in Canada gotten to the point where women with very legitimate reasons for caesarean are also denied reasonable access to care? Are we to the point where women are losing or denied their right to make a medical decision for themselves after being advised of the risks and benefits of their options? Have the “soft” indications for Caesarean become fair game for those seeking to reduce the rate of Caesareans?

Surely something could be done to help this mother develop a better plan (one she could actually agree with) – in conjunction with her care team.

After considering her options – and with the assistance of others, the mother drafted the following letter and gave it to her doctor in the hope of having a conversation about what her options were and to assert her right to make decisions regarding her own treatment. Identifying information has been removed.

Dear Dr. X;

I am writing because I have significant concerns about the recent changes to my care plan that you suggested at our last appointment and I would like to discuss my concerns and alter my care plan accordingly.

Until our last appointment I was under the impression that the care plan for the delivery of my child was to undertake a planned caesarean delivery with a concurrent tubal ligation under general anesthetic. It was my understanding that given the transverse position of the baby and several of my other health complications that include a neurological condition, PTSD, an ineligibility for regional anesthetic, and my own desire for no subsequent pregnancies that this care plan was the most appropriate and most likely to meet my needs for the safe delivery of my child. It is the care plan to which I was willing to consent and is the care plan that I still feel best meets my health care needs as it minimizes the risks of death or significant disability to either myself or my child and it avoids the risk of having to undergo an emergent cesarean.

At our last appointment you suggested that the care plan be altered, that I undergo an ECV in an attempt to reposition the baby, artificially rupture the membrane, and that an instrumental vaginal delivery be attempted at that time. Given that I am ineligible for regional anesthetic, I am under the impression that this would be done without an epidural in place and that if it were to fail that I would be subjected to an emergent cesarean under general anesthetic. Further this care plan would require a subsequent surgery in order to realize surgical sterilization.

It is my understanding that an ECV carries several significant risks, specifically:

· An elevated risk of placental abruption – that would necessitate an emergent cesarean delivery and may result in significant and life-long disability to my child.

· An elevated risk of an umbilical cord accident – that would also necessitate an emergent cesarean delivery and may result in significant and life-long disability to my child.

· A risk of enduring significant pain and discomfort as it is my understanding that regional anesthetic is contra-indicated in my case. This may be traumatic and could aggravate my pre-existing PTSD.

I understand that the risks of either a placental abruption or an umbilical cord accident are relatively low – however, the impact of these events should they occur is catastrophic and may mean life-long disability or death for my child. Further, it is my understanding that there is a significant risk of the ECV failing to succeed in repositioning the baby – in which case, an urgent caesarean would be needed.

For these reasons I do NOT consent to an ECV being undertaken to reposition my baby.

Should you proceed with the ECV absent my consent, and the baby be successfully repositioned, it is my understanding that you would then proceed to break my water and attempt an instrumental vaginal delivery of my child. It is my understanding that there are increased risks, both to myself and to my baby of a high-instrumental vaginal delivery. I also understand that my underlying medical condition makes pushing not advisable. I am aware that some of the increased risks involved could result in life-long disability to either myself or my child. Further, given that this is planned to occur in the absence of regional anesthetic, I anticipate that it may also be extremely painful and could be traumatic.

For these reasons I do NOT consent to a high instrumental vaginal delivery being undertaken to deliver my baby.

To be clear, I wish to minimize the risk of death or significant disability to either myself or my baby. Should the care plan that is ultimately chosen result in either death or significant disability – the impact would be catastrophic. I have four children and a husband – and as a result need to minimize the risk of long-term consequences that could result from the care plan chosen and am willing to accept an increased risk of less severe complications that may occur as a result of a planned caesarean care plan (risks like transient respiratory problems, an increased risk of infection, etc.).

As a result, I would like an opportunity to further discuss my treatment options and their associated risks and benefits with regards to this pregnancy – including any other appropriate consults so that we may develop together the care plan to which I am willing to consent, that best meets my health needs and those of my family both now and in the future. In particular, I would like to understand why and how the revised care plan better meets my health care needs in comparison to the care plan that was originally agreed upon.


Ontario Mother-to-Be

On March 10, 2014, she handed the letter to her doctor and he put it on her file.

Unfortunately, the OB managing the case decided that the mother’s specific objections to the care plan were not reason enough to alter the care plan. He scheduled the mother for an ECV. The first appointment she cancelled. The second, she showed up for, but declined consent and left the hospital.

The mother’s OB was unwavering in his commitment to the care plan he had decided upon – the only problem was that the mother did not agree with it. The degree of distress that was being inflicted on the mother was significant.

Then the baby moved head down – without a version. The mother was partly relieved, simply because a transverse baby is generally considered undeliverable vaginally and going into labour with a transverse baby has significant risk to the health and well-being of both mother and child.

However, the mother still did not want a vaginal delivery, particularly one in the absence of an epidural due to her neurological condition – and was doing the best she could to advocate for herself, including working with a psychologist, having a consultation with an anesthesiologist, and trying to get a second opinion or alternate care provider.

During this time the mother had an appointment with psychiatry – and the psychiatrist she met with indicated to her (as a kind of FYI) that advocating for a planned caesarean over a vaginal birth against the advice of her obstetrician could be perceived as a psychiatric indication that might warrant removal of capacity to consent. When the mother told me that, I have to admit to being floored.

Then it seemed as though the OB was going to relent, and agree to schedule the section. The Mother was told to expect a call from the hospital (she was already past 39 weeks gestation). She waited, and waited. Days passed, no call.

It seemed as though, the doctor had said one thing, but was proceeding with an entirely different care plan.

Finally, after waiting for the call for the Caesarean that never came – at well over 41 weeks pregnant the Mother went in for an induction. Not that she wanted to, but she felt as though she had no other choice – she could not wait any longer.

It was awful – the mother laboured 8 hours and was dilated to 7 centimeters before she was taken to the OR for a Caesarean. The Mother, at about 10pm, after several hours of labour yelled that she wanted a Caesarean – and was completely ignored. It took her husband getting the nurse to get the OB and demanding a section for the woman to gain access to the OR. They told her that the consent forms were signed for a section only as a “security blanket.” Then when she did go to the OR – a nurse had her fingers wrapped around the mother’s trachea and she could not breathe – the nurse told the mother “This is what you wanted.” Within seconds after that the mother was under a general anesthetic and the Caesarean was performed. Her son was born healthy.

Recovery from the Cesarean was complicated by an infection.

The mother intends to file a complaint with respect to her care, and, rightfully so - I applaud her courage for doing so.

Wednesday, May 21, 2014

What’s wrong with what Lamaze has to say about Cesareans?

Those that have read this blog for a while should know that beyond being a proponent of Cesarean by Choice – I believe in every woman being empowered to make the birth choice that best meets her needs and those of her family. I don’t believe any specific birth choice should be demonized or glorified (they each have their respective risks and benefits) – and that women should have access to care that best meets the individual needs of both themselves and their families. This means being given information on the risks and benefits of the options available, being given information on the likelihood of those risks and benefits materializing, being given information on what would happen should those risks materialize, being able to ask any questions that should arise, and being respected in whatever choices are made.

I loathe misinformation – and I particularly loathe misinformation that can result in significant harm to both women and their children or undermines their ability to make an informed choice in conjunction with their care providers.

As such, I’m really not a fan of what Lamaze has to say on the topic of caesareans (btw they’re hosting a twitter chat at 9PM ET, 6PM PT (#LamazeChat, #Cesareans, #CSections) ) – particularly if the following video is any indication of what they have to say on the matter.

First, let me say that listening to Lamaze on the topic of Cesareans seems as wise as listening to Similac on the topic of breastfeeding. Lamaze is a big company – and what does it sell: vaginal birth – or more specifically childbirth education classes to prepare women for planned vaginal deliveries. Planned Cesarean birth is in direct competition to planned vaginal birth – and those who choose Cesarean have no need for childbirth preparation classes that focus on vaginal birth. So it’s a wise business strategy for Lamaze to sell the idea that a caesarean birth is a bad birth and that taking their classes can reduce your risk of having a Cesarean birth. Unfortunately this strategy harms women and their babies in a myriad of ways and is based on a foundation of misinformation, half-truths and outright lies.

The video that Lamaze has produced – illustrates beautifully how Lamaze uses misinformation, half-truths and outright lies to sell vaginal birth (this may take a while). The video produced begins with the declaration that Cesareans can save lives….BUT…then goes on to decry the fact that one in 3 women have Cesareans in the US. This is where the web of lies and misinformation begins. It is true that upwards of 1 in 3 BIRTHS are via Cesarean, however, this does not mean that 1 in 3 women who give birth will have Cesareans. The rate of Cesarean birth in the US is roughly comparable to the rate of Cesarean birth in British Columbia, where approximately 31.4 percent of all live births were Cesarean sections in 2011. (Source: BC Vital Statistics Agency 2011 annual report, Figure 11). However, the headline rate of Cesareans masks important differences between different groups of women who are giving birth. In December of 2011, the Perinatal Services of BC produced a report that looked more closely at caesarean delivery rates in British Columbia using the Robson Ten Classification system. ( ) The report provides some important insights into which mothers are having Cesarean sections in British Columbia (and is probably pretty comparable to who are having Cesareans in the US). Among Rookie moms (first time mothers or nulliparous) – there are three distinct Robson 10 groupings – those with a single head down baby at term who go into spontaneous labour (Robson Group 1), those who have a single head down baby at term who are either induced or delivered by caesarean before labour (Robson Group 2), and those who have a single butt first (breech) baby (Robson Group 6). Among moms in group 1 (rookie mom, head down singleton baby, spontaneous labour at term) one in 5 delivered by Cesarean (19.8 percent), those in group 2 (rookie mom, head down term baby, induction or CD before labour) nine in 20 delivered by Cesarean (44.5 percent) and among first time moms with a breech baby 19 in 20 were delivered by Cesarean. Among those who had given birth before and did not have a uterine scar and had a head down baby: fewer than one in 38 (2.6 percent) of those who went into spontaneous labour at term (group 3) delivered by way of Cesarean, and among those who either had labour induced or caesarean delivery before labour (group 4) the caesarean rate was 13.1 percent or slightly more than 1 in 8 . Among those with a head down term baby who had given birth before via caesarean (group 5) nearly 8 in 10 delivered by way of caesarean (78.9 percent). Those who had given birth before, including those who had a uterine scar and had singleton breech (group 7) had a caesarean delivery rate of 87 percent. The Cesarean delivery rate among moms of multiples (group 8) was more than 7 in 10. All those with a transverse or other abnormal presentation had a Cesarean rate of 80.6 percent or more than 8 in 10. Women who had a single vertex pregnancy that was delivered prior to term (less than or equal to 36 weeks gestation) had a caesarean delivery rate of a little less than 3 in 10. Those who couldn’t be categorized into the Robson 10 system, either due to incomplete information or otherwise had a Cesarean delivery rate in excess of 9 in 10 (93.1 percent).

Ideally, it’d be nice if the Robson system would distinguish between those who elected caesarean, and those who did not as important information is unavailable when the treatment plan is unknown. Many women might have elected for or chosen Cesarean and as a result this table does not give a good indication of the percentage of planned vaginal births that result in vaginal deliveries. It would also be nice if nulliparous moms who were expecting multiples were separated from those who had been to the childbirth rodeo before. Further, an even better understanding of Cesarean rates (and a woman’s individual risk of having one) could be had if rates were further stratified into other variables like age, maternal BMI, expected large baby, small maternal stature, etc. But atlas I digress.

At any rate – the use of the Robson 10 groups clearly illustrate that there is a lot of variation at work beneath the headline Cesarean rate, and that the use of the headline rate likely over-estimates the risk of having a caesarean for many women, particularly those who have been deemed to be “low-risk” pregnancies (singleton, term, head down with healthy mothers). The take home message for moms to be is the following: your risk of needing a Cesarean during labour and delivery is an individual risk that is a function of a variety of individual factors and to better understand the likelihood of YOU needing a Cesarean, you need to have a detailed conversation with a qualified maternity care provider.

The Lamaze video then goes on to declare that the rate of Cesareans is “Double what Unicef and the World Health Organization” recommend. This is one of those zombie statistics – it simply refuses to die. In 2009, the World Health Organization retracted its recommended rate of 15 percent because “there is no empirical evidence for an optimum percentage” and “what matters is that all women who need Cesarean sections get them.”

Lamaze in their video then proceeds to delineate the risks of Cesarean birth to moms (post-operative infections, complications from anesthesia, blood clots, injury to organs, infertility and placental complications in future pregnancies) and babies (including accidental surgical cuts, intensive care admissions, premature delivery and breathing difficulties at birth and beyond). I’ve got call a very loud foul on how this information is presented for a few reasons: 1. Lamaze does not distinguish between planned and unplanned caesareans, and I should note that most unplanned caesareans are the result of trials of labour that were abandoned. The risks to mom and baby are very different depending on if the caesarean is planned or unplanned. 2. Lamaze does not put the risks into any kind of context – is the risk being described a near certainty or a rarity? 3. Lamaze does not detail any of the benefits of caesarean delivery. 4. Lamaze does not detail any of the risks of vaginal delivery. All this part of the video seems to do is to motivate women to avoid caesarean delivery (note I’m only 39 seconds in at this point).

Then comes the hard sell: Lamaze tells women that they can reduce their risk of Cesarean in the following ways and that doing so is “pushing for better care”:

1. Get educated – take a Lamaze childbirth education class.

This is where women should just stop listening to what Lamaze has to say because it’s abundantly clear that Lamaze is not in it for the benefit of mothers and babies, Lamaze is in it to sell their product: childbirth education…and more specifically education on “natural childbirth”. The video encourages women to find a class near them, to get facts and support from a “certified educator” and to “learn from other moms”. No evidence is provided that shows a woman’s individual risk of having or needing a Cesarean is modified as a result of taking a childbirth education class – Lamaze or otherwise.

2. Choose a provider and birth setting with low caesarean rates. The video encourages women to ask about their provider’s caesarean rate, the caesarean rate of the hospital or birth center and that if the rate “sounds too high” to shop around and switch providers.

Here is where Lamaze’s advice takes a potentially dangerous turn. I have a major issue with using Cesarean rates as an indicator of quality obstetrical care. Encouraging women to choose a provider or birth setting based on rates of Cesarean can lead women away from quality care and towards outcomes that are utterly tragic. A provider or location with a high Cesarean rate might be an excellent choice – even for a woman who desires to avoid a caesarean and to give birth vaginally if doing so is safe for herself and her baby. Conversely, a provider with a low caesarean rate might be an excellent choice even if the mother wishes for a maternal choice caesarean. Providers and facilities with high Cesarean rates might be caring for a high-risk population, they might be respecting maternal choice caesarean, and/or substituting Cesarean for instrumental (forceps or vacuum) delivery. If a provider or facility has a low Cesarean rate it might reflect inadequate access to Cesarean delivery that could put mothers and babies are risk of serious and life threatening situations (death and long term disability). Mothers need to choose a provider who they can trust and who is qualified to advise them on the best care for both themselves and their babies – and facilities that are equipped to ensure that access to the best care is available. The best providers, likely don’t really give a damn about their Cesarean rates but care deeply about making sure their patients (both moms and babies) make it through the process as safely as possible. The best care providers also care a great deal that the women they serve do not feel violated as a result of their birth experience and are bound by professional ethics and standards.

The video then goes on to encourage women to hire a doula for labor support – as it will shorten labor, reduce pain, and help the father or birth partner support the laboring mother.

I have mixed feelings about doulas – I’m sure some are great, and are a tremendous resource to women as they go through the birthing process. But some are ideological zealots who frustrate the relationship between a woman and her care provider. Ultimately, I have a hard time seeing how the presence or absence of a doula would mitigate an individual woman’s risk of needing a caesarean section. An epidural on the other hand, does do many of the things that Lamaze claims doulas do: it can shorten labour, is a proven method of pain relief, and if you aren’t in pain, you likely aren’t cursing out the father of your child, which probably helps him to support you. Further, with an epidural in place, if you ultimately do need a caesarean it can often be topped up and allow you to avoid a general anesthetic…I’ve even heard that an epidural can be placed but not dosed until the mother feels it is necessary.

I’m now at 1:37 in the video – the point where Lamaze encourages women to “let labour start on it’s own”. It claims that induction carries health risks, that you’ll know baby is ready to be born, and that your body will be ready for birth.

Generally speaking, I do not believe that care providers recommend induction unless they believe that the risks of induction are less than the potential benefits of induction. Further, there is recent evidence that labor induction might be tied to a lower risk of C-section ( according to a review published in the Canadian Medical Association Journal. The same review found that there were also significant benefits for the fetus including a lowered risk of fetal death and admission to a neonatal intensive care unit. I’m also going to criticize the video for failing to indicate what the risks of induction are, or the magnitude of those risks.

At 1:50 the video encourages women to avoid “routine” interventions. It claims that continuous monitoring can falsely signal trouble leading to a caesarean, that being confined to a bed can make it harder to deliver, and that water and food restrictions can leave you weak and exhausted. The video encourages women to ask their care providers about the interventions used.

Here are my problems: 1. I’d be far more worried about trouble not being detected and falsely believing that everything was okay with my baby when it wasn’t. 2. Many hospitals do not require that mothers be confined to beds, some have “walking epidurals”, and 3. Experiencing hours of unrelenting pain can also leave you feeling weak and exhausted. I agree that women should ask their providers about the interventions or procedures that are used, and that they should be apprised of the associated risks and benefits.

At 2:09 the video encourages a woman to question a Cesarean if either mother or baby are in no immediate danger. It encourages women to ask what the alternatives are and what the risks of waiting are and to understand the short and long term risks of surgery and that long labor is not a medical reason for a Cesarean.

Again, in my experience – qualified care providers generally do not recommend proceeding to a Cesarean unless they feel that the risks of continuing with a vaginal delivery outweigh the risks of proceeding to a caesarean. There may be benefits to either the mother or baby to avoiding a situation where the mother has been utterly exhausted by labour and a real risk to the health and safety of the baby has materialized. In some facilities – OR resources are not continuously available and if the probability of vaginal delivery is low, it may not be worth the risk of having the resources be unavailable should they prove to be needed. Further, recovery from a Cesarean may be more difficult if labour has be unnecessarily prolonged. Lastly, the short and long term risks of Cesarean delivery (and vaginal delivery) would ideally be discussed and understood long before the day of delivery arrives.

The video then goes on to discuss Vaginal Birth After Cesarean, declaring it is a reasonable option for most women with previous caesarean, that routine bans are not based on evidence, and that VBAC success is as high as 74 percent.

Lamaze fails to provide the risks and benefits of VBAC – and fails to mention that in the event of the most serious complication of VBAC, uterine rupture, that immediate access to surgical care is needed to avoid lifelong disability or death for either mother or child. Further, the VBAC success rate of 74 percent is in an ideal case – where the woman had the prior Cesarean for a non-recurring reason, has a low-transverse scar, and is carrying a singleton pregnancy.

The video ends with the statement: “push for the safest, healthiest birth possible”.

Too bad that what Lamaze is advocating for likely is not “the safest, healthiest birth possible” for many women - and might lead many women to distrust their care providers, feel tremendous guilt should they ultimately need or choose cesarean and might result in birth trauma, lifelong disability or death for some women and their babies.

Wednesday, May 7, 2014

Why the lack of Private Health Care threatens Medicare in Canada

Canada is unique in the world in the sense that its universal publically funded healthcare system is a domestic monopoly. Under the Canada Health Act, domestic access to privately funded health care services that are covered by the provincial health insurance plan is prohibited. If it is a service that is not covered under the provincial health insurance plan – like a cosmetic nose job or a vasectomy reversal – then access is through the private system and patients pay out-of-pocket. It is interesting to note that waits for medically necessary, but “elective” procedures (note: elective simply means scheduled in advance) are rather endemic, meanwhile waits for medically un-necessary elective surgeries (ie. The cosmetic nose job) are fairly minimal. It is a stark contrast.

The provincial health insurance plans are funded via tax revenues and medical service plan premiums (note these are nominal premiums that do not vary as a result of risk – really more of a head tax than an insurance premium). It should be noted that not all provinces in Canada charge a medical service plan premium. The province also determines which services are covered and which services are not covered – and this also varies between provinces. All urgent and emergent medical care in Canada is publicly funded and considered a priority – as such, after the resource needs of those healthcare demands are taken care of in priority to the non-urgent or elective healthcare demands. However, the resources available to meet those demands are not infinite, and as a result the remaining health services must be rationed, simply because there is not enough resources to pay for everything that doctors and patients have decided are needed. However, even between elective services, the priority of those services varies and so access to healthcare services is again limited. Those whose healthcare needs are determined to be of the lowest priority face the longest waits – and it is theoretically possible for a patient deemed “not a priority” to never gain access to that service in Canada even though that patient and that doctor have determined that having access to that particular service is in the patient’s interest. That patient has paid their taxes and health insurance premiums, but cannot access the benefit to which they are entitled because their needs are determined to be lesser than other people’s needs in the system. Further, because that patient never accesses the health service that they needed – the government never has to pay for it, keeping health expenditures artificially low. It should be noted that the government does not track the number of health services “needed but never delivered”. That patient has very few options: they can go without the service entirely or they can go abroad to access the service. The one option the patient does not have is to pay out of pocket to access the service or guarantee access to the service in Canada because this would contravene the Canada Health Act.

Many – including Dr. Danielle Martin, the head of “Doctors for Medicare” – have argued that this status quo (a public monopoly on the provision of services covered by the provincial health insurance plan) should be defended against those who would like to see a parallel private health insurance or “dual practice” emerge in Canada. They fear that allowing privately funded healthcare will weaken the universal public healthcare system. Theoretically, this is possible in a variety of ways:

1. The private system would require doctors and nurses – doctors and nurses who would be exclusively available to the public system if no private system exists. To the degree that staff shortages already exist, they would be exacerbated, and the public system would struggle even more so to meet the needs of the public. The competition for human resources could drive up wage costs, and put further pressure on healthcare expenditures.

2. The private system, and the dual practitioners would have an incentive to keep wait times long in order to steer people into the private system for their own economic benefit.

3. The private system would take the “cheap and cheerful” patients who are most profitable and leave those who are complex and expensive to care for to the publicly funded system. As a result, the cost per case handled in the public system would increase.

4. The complications that result from health services delivered in the privately funded system, some of which may be urgent or emergent in nature, might be left to the publicly funded system – increasing demands for non-discretionary resources and leaving even fewer resources for those with elective health care needs.

5. Healthcare services might be “inappropriately” used, in other words people and their doctors might decide to undergo unnecessary procedures.

6. Public resources would be needed to accredit facilities providing privately funded healthcare services.

7. People might become less willing to pay towards the publicly funded universal health system if they carry parallel private health insurance, and as a result attempts to bolster tax revenue in support of that system would be met with even greater resistance.

Indeed it is possible, that a parallel private system could, in theory, result in a deterioration of the universal publicly funded healthcare system.

It is also possible, that a parallel private system could, in theory, strengthen the universal publicly funded healthcare system, and that the absence of a parallel private system results in harm to Canadians and the universal public healthcare system.

1. A parallel private system could expand employment in the healthcare sector – many jobs that would be created would be high-quality and high-paying jobs. The competition between the private and public sector could improve working conditions for those employed in the healthcare sector, making it a more attractive field to work in.

2. If remuneration for procedures in the private sector was regulated, the incentive to steer patients into the private sector from the public sector would be ameliorated. This would be particularly true if there were strong regulations with respect to the ownership of private healthcare facilities. It is irrational to think that a physician would care if his or her services were publicly or privately funded. Further, the participation of the physician in the public sector could be regulated such that he or she would be required to fulfill their obligations to the public sector. For example, private practice might be allowed only if the physician meets a specified number of hours of public service. This is done in some countries with parallel private systems that allow dual practice. Note: Many physicians in Canada find that the number of OR hours available in the public system is far below what they would like. Further, there is some evidence that the quality of healthcare services relies on practitioners being able to perform an adequate volume of services.

3. The impact of cherry picking patients who are “cheap and cheerful”, depends on how healthcare services are funded. Currently, healthcare services in Canada are funded on a combination of “block funding” and fee for service. It is true that the publicly funded health care system would lose the portion of the funding that is associated with the fee-for-service for that particular patient. However, in a circumstance where demand for publicly funded services exceeds the supply of publicly funded services, the money not spent on that patient WOULD most likely still be spent on some other patient, assuming the budget for publicly funded health services remains the same. The existence of a parallel private system might bring demand for publicly funded services closer to the supply of publicly funded health services.

4. The complications of delayed access to care might be avoided as would some of the complications and their costs associated with foreign access to care (some Canadians access care in Asia, Mexico, India and other places with burgeoning health tourism industries and unfortunately that care is not always of the same standard as care that is provided here).

5. A parallel private system might enable justified restrictions to accessing care in the public system, care that might be considered inappropriate or inefficient use of public healthcare dollars. In short a physicians’ ability to say no might be improved. Further, the decision whether or not a patient submits to a treatment should not be a matter of policy – if the patient and the physician have determined that the patient would benefit from undergoing the procedure, he or she should be free to do so – even if it means they need to pay out of pocket.

6. Public resources are needed to accredit and inspect all sorts of private businesses – there is no reason to think that the resources needed could not be raised from the revenues generated. The cost of accreditation might be more than covered by the increased tax revenue from the private health industry.

7. The willingness to pay for public services in general depends on whether or not people believe they are getting good value for their tax dollars – to the extent that a parallel private system might improve the efficiency and effectiveness of the public system, the public might become even MORE willing to support the public healthcare system. To the degree that a parallel private system expands the tax base (by increased employment and reduced losses of income as a result of healthcare waits avoided) – resources available to the public system might be improved.

8. A wait time guarantee in the public system could be meaningfully implemented if recourse to a parallel private system was available.

9. The laws and regulations that govern the delivery of health services in Canada could be brought into compliance with the Canadian Constitution.

10. The ability to “whistle-blow” about quality deficiencies might be improved as both patients and providers would no longer fear losing access to local healthcare or local employment should they disagree with what is happening.

Allowing private health insurance doesn’t mean abandoning the concept that access to health services should be a reflection of need, not ability to pay and it could enable a strengthening of the universal public healthcare system. If a parallel system could enable the public system to operate more efficiently with stronger guidelines and oversight, it is even possible that the set of services available in the universal public system could be expanded to include dental care and pharmaceuticals (much like in the UK). Maybe there’s good reason that Canada stands alone in its prohibition against privately funded healthcare: it’s an outdated model that simply doesn’t work. Many countries have strong universal public healthcare systems AND parallel private health insurance and achieve excellent healthcare outcomes at reasonable levels of healthcare expenditures – it is time we joined the ranks of the countries with the best healthcare systems in the world.