“Foreseeable Natural Death” in Bill C-14: An Unclear and Undue Restriction?

Guest post by Michael Nafi, Department of Humanities, Philosophy and Religion, John Abbott College 

Bill C-14 on Medical Assistance in Dying has given rise to much debate in the Canadian House of Commons, in the mainstream media and various blogs, with both consensus and dissension stretching across the French/English language divide. The tide is unlikely to subside as the Bill moves to the Senate. Furthermore, as the parliamentary session nears its end, speculations abound on the fate of the Bill after the Liberal majority government today missed the June 6th deadline for its required legislative response to the Supreme Court (SCC) ruling in Carter v. Canada.

Critics have pointed out a number of shortcomings of the Bill and called for a number of amendments. However, regardless of the final form the law might take, there can be little doubt that the issue of medical assistance in dying will be revisited in the future on at least two fronts: i) the exclusion of persons under the age of 18 from such medical assistance and ii) the rejection of the possibility for persons who anticipate a deterioration of their health to provide advance directives to end their life in the future.… Continue reading

Physician billing in the era of big data

I was in sunny Edmonton last week, giving a paper at the University of Alberta on the ethics of physician billing. (I always enjoy being back in any part of the country where the sky occupies what I consider to be the correct proportion of one’s visual field, i.e., approximately 2/3rds.) The paper can be found here, for those who are interested. In it, I basically complain about the failure of the medical profession to treat billing as an “ethics” issue. Instead, the profession tolerates, and in some case encourages, a “compliance-based” culture, where any strategy that falls short of outright fraud is essentially considered acceptable.

There is a bunch of subtle argumentation in the paper about why billing should rightly be regarded as an issue of professional ethics, and not merely personal integrity. There are also a bunch of great examples of gamesmanship – a topic that is of perennial interest to me.… Continue reading

Physician-Assisted Dying: What Now?

Five years ago, I agreed to join an “expert panel” of the Royal Society of Canada. Our mandate was to provide a broad assessment of end-of-life care in Canada, and to make recommendations on how it might be improved. One of the recommendations that we made in our 2011 report was that there was no ethical justification for the maintenance of the criminal prohibition preventing physicians from helping their critically ill patients to die a dignified death, one that conformed to their wishes, and avoided them needless suffering.

I was therefore naturally very pleased when the Supreme Court of Canada issued its judgement in the Carter case, declaring that those articles of the Criminal Code were incompatible with Canadians’ Section 7 rights to life, liberty and security of person. Looking back at the 1993 decision in which a 5-4 majority had ruled that those articles were not in fact unconstitutional, a unanimous Court this time argued, in essence, that the empirical environment in which it was now being asked to render judgment had changed.… Continue reading

Mindfulness in an Unjust World

Mindfulness meditation has become very popular. Its exotic Buddhist origins combined with the mounting evidence produced by Western science that meditation is (mostly because of brain plasticity) good for us, makes it very appealing. Many therapists are now designing new mindfulness-based cognitive and behavioural therapies, and some physicians now recommend it to their patients. Mindfulness-based programs are used to treat depression, anxiety, chronic stress, chronic pain, and so on.

Being mindful is being able to focus our attention, moment by moment, on stimuli such as one’s breath or bodily sensations and, in doing so, to step out of the constant flow of thoughts and feelings that inhabits our mind under normal conditions. This is why many think that meditation “quiets the mind”. It is recognized that thoughts and emotions will always irrupt, but such mental states should be welcomed in a non-judgemental manner and objectified, i.e. observed as external phenomena by the reflexive and compassionate self that we are when we practice mindfulness meditation.… Continue reading

L’Affaire Bolduc

The honeymoon is over. Three months more or less to the day after having been voted into power in Quebec City with a shiny new majority, Philippe Couillard’s government finds itself embroiled in its first, honest-to-god political scandal. It seems that Yves Bolduc, a physician, who is now in Cabinet as the Minister of Education, but who was Minister of Health under Jean Charest, racked up $215 000 worth of bonuses as a practicing physician while he was in opposition. The opposition, and a good part of the chattering classes, are now clamoring for his head. No less a figure than Claude Castonguay, the father of Quebec’s system of public health insurance, wrote an open letter to Philippe Couillard calling upon the Premier to sack his Minister.

Some context: somewhere close to 30% of Quebeckers do not have a GP. In order to attempt to lower that number, the Charest government (with Bolduc as Minister of Health) instituted an incentive scheme to get general practitioners and family physicians to take on more patients.… Continue reading

Think like a jackass

So everyone’s been making fun of Steven Levitt and Stephen Dubner lately, thanks to a story they recount in their new book Think like a Freak (sequel to Superfreakonomics, sequel to Freakonomics). It concerns a meeting they had with David Cameron, sometime before he became the British Prime Minister. They offered him some advice on how to deal with the problem of expanding health care costs in the U.K.. The problem, they said, was that government was giving it away for free:

What’s wrong with that? When people don’t pay the true cost of something, they tend to consume it inefficiently. Think of the last time you sat down at an all-you-can-eat restaurant. How likely were you to eat a bit more than normal? The same thing happens if health care is distributed in a similar fashion: people consume more of it than if they were charged the sticker price…

We tried to make our point with a thought experiment.

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Perverse incentives in Canadian health care

I notice that Dr. Danielle Martin is going to be giving a talk on Monday (May 12) on campus here at the University of Toronto, so to celebrate the occasion I thought I’d discuss Canadian health care for a bit.

Incidentally, for those who don’t follow these things, Dr. Martin recently quickened the pulse of Canadian nationalists everywhere by smacking down a Republican Senator on television:



This video quickly came to occupy a place in the policy wonk’s heart, like an understated version of the “Joe Canadian” rant. (For those of you who missed that one, see here:



One cannot help but be impressed by her poise and self-confidence as she challenges his talking points. At the same time, people familiar with the state of affairs in Canada may have cringed a bit during the discussion of wait times. Because while the Canadian health care system performs very well in certain dimensions, in the area of wait times we are an international underperformer.… Continue reading

On two-tiered medicine in Canada

My boss, Mark Stabile, has an op-ed in the Globe and Mail today, arguing against two-tier health care in Canada. He’s the kind of economist who is interested in facts, and he cites a few. For example, with an added tier of private medicine:

there is little evidence that wait times in the public system go down. And there is little evidence that a private system reduces the costs of public systems. In fact, in some jurisdictions, overall costs in the public system actually went up in those cases where the tax system subsidizes people who purchase private insurance (as Canada does). Over all, those systems that have private insurance have had to continue to grapple with issues of costs and access, much as we do here in Canada.

Now I’m the kind of non-economist who is quite interested in incentives, so I find it interesting to speculate about why allowing people to opt out of the public system and purchase health care privately would not free up resources in the public system.… Continue reading