There seems to be no end to our healthcare demands, but there does appear to be a limit to how much tax we will pay, says Peter Brindley

Like me, my neighbour and friend has strong opinions. Accordingly, he occasionally “delights” me by leaning over the fence and venting his spleen. His specialist topic is how public healthcare should be run. He invariably adds that doctors waste money and are robbing future generations. I wholeheartedly agree. I then add with a wry grin how we could start reducing costs by refusing elective surgery for those who still smoke, and by not offering machines at the end of natural life. Given his two pack a day habit and his older frail parents, this usually amicably ends the conversation. He’s a friend and won’t mind me writing this. After all, he also begrudgingly agrees that for every problem, there is a simple solution, and that solution is usually wrong.

It’s enough to make me sympathetic towards those working in government. Oh, that’s right, I hadn’t mentioned my neighbour’s job. We are both public servants: me a doctor, he a retired administrator. We are both verbose when it comes to outlining what has gone wrong, but rather quiet when it comes to how to put it right.  

Everyone—me and my neighbour included—seems to know their rights, but few of us know our responsibilities. Accordingly, we have both heard and delivered orations about the changes others need to make. We have both witnessed and exhibited comparative silence when it comes to what we should do ourselves. It is easy to ask for more, but that money needs to come from somewhere.

Moreover, many of us sputter indignation when told that our monthly tax contribution was likely used up with the first day spent in hospital, or the first few bricks of a new construction project. Doctors and patients and administrators alike howl whenever others talk about controlling the budget in any area that afflicts their family, or department, or pay cheque. The word ration comes from the same root as rational, and as a society we appear to be failing at both. We all seem hellbent on investing in the past rather than the future, and in grabbing as much of the pie as we can. He who dies with the most wins. It’s a shame that this applies to tubes and well as trinkets.

There seems to be no end to our healthcare demands, whether patient or practitioner. But there does appear to be a limit to how much tax we will pay. There is also a grey tsunami on the horizon, and the environment is paying the price for our “have it all” lifestyle.

It is trite but true that “healthcare” is also a misnomer given our illness model. We spend an eye-wateringly disproportionate share on the last months of life. Cost is racing far ahead of revenue, but no group—patients, providers, or politicians—is really applying the brakes. The bottom line cost is the top line expenditure for government. These points are unassailable; the rest is an ugly fight. The solution: well, if only we knew.

Talk is cheap, but healthcare is definitely not. In 2011, it was estimated that the United States spent over $2.3 trillion on healthcare. This is twice what was spent in 2000. Much like the climate change discussion, future projections do not even have the decency to be linear, and denial abounds. If this continues then by 2040 one of every three dollars spent in the US will be on health. That country already spends 1% of its entire GDP on intensive care. Elsewhere, smug academics tut with indignation even though their countries are not far behind. Like the boiling frog fable, we’re all likely to be cooked.

On the subject of rising temperatures, we can look to climate (in)action to guess where this is headed. We know that we really should do something, but that would require selfless action, not self-aggrandizing words. To paraphrase Churchill—as we all enjoy (over)doing—“don’t tell me what to do while I’m busy telling you you what to do.” We should admit that healthcare is not only great for business, it is great for those of us in academia. I know of no better way to publish a manuscript than by declaring a call to arms, but without a battle plan.

Healthcare with a capital H is also too big to fail. It employs too many people, and commands too many votes. We implore our leaders to act boldly. However, if they had the temerity to do so we would kick them out on their ass.

If we “imagine”—John Lennon style—there’s no healthcare then get ready for uncomfortable truths. You and I would have to be responsible for both our illnesses and our wellbeing. We would also have to change our gloriously pampered life and stop blaming others. We might have to exercise rather than just purchasing a gym membership, and cook rather than watching celebrity chefs. We would have to accept that life is finite. I don’t want this anymore than you do. When we say we want freedom, we really just want freedom from responsibility.

It is a rare day when I do not hear complaints about the lack of services. I should just smile and move on, but find myself increasingly pushing back against simple answers to complex problems. For example, would you rather we charge punters directly (“how dare you, I already paid my taxes”), or rob from another service (“we’ll get cancer wait times down by delaying hip surgery”), or further increase taxes (“I’m not paying: Cayman Islands anyone?”). Instead, we drag out the old donkey and talk about trimming its fat. However, this cannot be done forever, and that donkey is already wheezy and thin.

Meanwhile, those of us in the white coats and back offices are also getting fat off this system. This is why my upscale neighborhood is stuffed with well paid civil servants. I can lean over the back fence and admonish any number of medical specialists, judges, politicians, and police officers. My point is not that I know what service we should delist or who we should let go. In fact, it should be clear that I do not have the answers any more or less than my friend and neighbour.

We are like so many others: dual certified in identifying problems and blaming others. Change, like charity and economy, should start at home, or in our case over the back fence. You are welcome to join our conversation; we could use any wisdom.  

Peter Brindley, professor in the department of critical care medicine, Department of Anesthesiology and Pain Medicine, and the Dosseter Ethics Centre, University of Alberta, Edmonton, Canada. He is on Twitter @docpgb

Competing interests: None declared.