Chaplain's Corner

Back in September I had the privilege of attending a day of the Hospice and Palliative Care Conference that is held each year in Winnipeg.  I also had the privilege of being one of the presenters.  As I sat in the first session of the morning, Dr. Bashin Jiwani, Ethicist & Director, Fraser Health Ethics Services, Fraser Health Authority, gave a presentation that I found very interesting.  In that presentation he spoke of one of the silent but powerful pressures that challenge ethics in health care: meritocracy. 

Now, I had never heard the word before, but I was pretty sure I knew what it meant.  Dr. Jiwani defined it as it relates to the business of ethics in health care as: only the people considered to have “merit” receive consideration, resources and opportunity.”  I did some further research and my suspicions were right.  “meritocracy” has to do with rewarding people based on their individual merit (i.e. talent, intelligence, ability, likelihood of responding to treatment, etc).

Now, Dr. Jiwani was not for a minute stating that this is a good system to use in evaluating who receives the health care and it’s associated resources in our Canadian context.  He was simply stating that this is a common system, rarely named, that subtly used to make determinations about the allocation of resources in health care.

When health care ethics is the topic of the day, there will often be exercises that are used to get people thinking about these issues.  One common exercise goes like this:

There are five people; a world class cancer researcher, a teenage girl, a 35 year old mother of six children, a single disabled man and a 90 year old woman who has heart disease. They all took a sight seeing boat ride one afternoon when the boat began to sink.  The captain of the boat died of a heart attach because of the stress of trying to deal with the sinking of his boat. There are only 4 life vests in the boat. Who gets a life vest and why?”

Well as this ethical problem is discussed, often the idea of meritocracy surfaces.  One person in the group might say, “Well, the cancer researcher for sure should get a vest.  Imagine how many people might benefit from the work he is doing.”  Another might chime in, “Well, the mother of six should surely get a vest; she has so many people counting on her.”  Another might say, “As hard as it is to say this, I think the 90 year old grandmother should be the one who doesn’t get the vest.  She has lived a long life, she is sick anyway; she has little to contribute anymore.”  But then another chimes in, The disabled guy, maybe he should be the one not given a vest, he will only spend the rest of his life dependent on society for help.”  And then another interjects, “But the teenaged girl, she’s young and could probably swim, so why not give the vests to the others and not give one to the person who has the best chance of survival without a vest.”

Now the purpose of these exercises, as absurd as them may seem, is to help everyone understand that they come to the discussion, with some sense within themselves of what should be done, but the reason behind our choices is often unexamined.  And did you notice how many of the possible solutions were based on a system of “meritocracy” because they were reasoned based on some merit or lack of merit within the individual being considered.

Thankfully we are rarely put into these kinds of situations, or are we?  Maybe not in that focused a situation, but everyday in South Eastman Health, decisions have to be made about how we use the finite number of healthcare dollars provided to the Region by Manitoba Health.  The decisions may not seem as “life and death” but they are important none the less, for at the end of every decision is the well being of a person or a group of people.

Resource allocation is one of the most difficult jobs.  Every one of us deals with it every day.  The teenaged girl who makes money babysitting deals with it, the college student going through university on student loans deals with it; the young couple newly married who need to buy a new car deal with it, businesses deal with it, social services deal with it, governments deal  with it.  There is a limited amount of money available and more places to spend it that there is money to go around.

Most of the time we make decisions based on what we deem to be the most meritorious; where will get the best value for our dollar.  Whose need is the greatest or who will be served best by receiving the care.  But behind every one of those questions is some value system that determines on what merits we make those judgments. And the business of allocation based on merit becomes really problematic when you get into the realm of social services and health care.  Do you want to decide to provide potentially life saving care for one person, but to deny it to another because of some determination of merit?  Who would determine what the merits were?  Who would decide who matches up and who doesn’t match up? 

The recent discussions in Quebec about euthanasia raise this point in the extreme.  When scarce health care dollars are at stake, do we provide life sustaining treatment to a severely disabled person or do we save them for the able bodied? 

I think it is at this point that economics run headlong into values.  The values of the Christian faith, one based on “grace” not “merit” esteem every life of value and reckon God alone as the giver and taker of life.  Consequently in the interim, in those days between conception and death, those who have roots in the Christian faith, believe it is important to serve everyone, regardless of their personal “merits” thus reflecting God’s grace.

But in Canada, we live, as we are so often reminded in a multi-cultural and multi-faith community where the grounding values of one group must not be given priority over the grounding values of another.  So the hard work of determining how to use the finite dollars allocated to Health Care continues.  Every day, people are making decisions, some as small as “should we use a $30.00 piece of equipment or the $120.00 top of the line item?  Or should we begin working towards the goal of building a new Personal Care Home so that the year long wait for admission can be addressed or should we invest more money instead in Home Care resources so that we can support people in their homes?

I for one am grateful that I am not in a position to have to make those allocation decisions.  I know many of the people who do, and they are good folks with caring hearts who have a much bigger view of things than I have.  I suppose at some point we must accept the fact that limited resources demand that some system of merit be used to determine the allocation of funds.  It is simply unavoidable.

We must remember that God can be gracious to all, because his resources are limitless.  That unmerited favor in a pure sense is the prerogative of God’s alone, for unlimited resources are His alone.  We humans and the institutions we create to serve one another will always have to wrestle with the limitation of resources and consequently the reality of some system of merit to determine how those resources are allocated.  May God give us wisdom to establish merits in a way that serve the most the best.