There’s an unwritten rule in Canada: never miss an opportunity to big up all things Canadian. It is likely annoying to others, so, dear reader, please excuse me for channelling the 1988 song “If I had a million dollars” from the Ontario band, the Barenaked Ladies. My goal is to encourage a medical thought experiment. In brief, imagine that you have been gifted a million dollar with a simple remit: “do the most good for others.” My first rhetorical question is whether you would think outside of the box, or just plow a million more bucks into more of the same? If “the same” then you have your answer: more dosh; no further problems. However, I just don’t buy it.
If we accept the need for “better” not just “more” then we should think through the “what” and “how.” Moreover, while doctors typically learn an estimated 1600 medical words during medical school, far fewer will have the eloquence to tailor a deserving message for our generous donor. This donor will be less interested in whether you have the diagnostic acumen of Sir William Osler (another Canadian, sorry), but mightily concerned if you don’t have the fortitude to overcome bureaucratic red tape. They will also want to know that you will stick with your project after it ceases to be fun. In Canadian terms, we don’t need people cursing the cold; we need those who can build and maintain a shelter. Lives may depend on it.
This thought experiment works on another level. After all, one million dollars is simultaneously a big and small amount. This will not buy a magic wand; you cannot build a new hospital, nor can you bring a drug to market. You will have to be simultaneously practical and radical. In 1988, when the Barenaked Ladies penned their ear worm song, the lyrics were plausible: one million dollars was enough for a house, furniture, car, and even a fur coat (“but not a real fur coat” etc). But in 2020? In first world healthcare? You better be careful what you wish for.
This thought experiment highlights how blinkingly expensive first world healthcare is, and the difference between cost (i.e. sticker price) and value (i.e. how much it means to others). Accordingly, my son and I spent a chilly Canadian afternoon estimating monetary costs on the back of an envelope. Apparently, with one million Canadian dollars, we could only buy a third of an MRI machine or a sixth of a helicopter, but then you’re saddled with operating costs. If usual medical practise norms continue (“never say die”) then one million dollars would fund approximately 650 days in the intensive care unit. However, more money might only inflate our biomedical obsession. If so then the money will not decant that crowded emergency department for long.
So, what do patients, doctors, and donors value? It is tough to know, especially if we haven’t previously stopped to think and ask. Perhaps, we should put the money into comprehensive end-of-life care, given that death rates are holding steady at 100%. Our estimates suggest that one million dollars would cover end of life care for approximately 100 people. Sounds substantial, until you understand that this is a country in which approximately 70% of all citizens die in hospital, and a quarter in intensive care. Alternatively, we could transform twelve first world medical students into doctors, or we could educate thousands of our fellow citizens. We could fully vaccinate 5000 people or invest the money in explaining why vaccination is one of healthcare’s greatest gifts. We could plant 5000 trees, or feed and clothe a family for life. Accordingly, this thought experiment is also a reminder that not all healthcare occurs in hospitals.
The complexity of healthcare spending should highlight why I was so impressed by five UK trainees who embraced the “If I had a Million Dollars” challenge, and why I encourage others to do the same. The first such event occurred at the UK Intensive Care Society Meeting in Birmingham, December 2019. Five Critical Care Registrars took to the stage and I had the privilege of judging: Dragon’s Den style. Their pitches were cogent, clever, and costed. Importantly, all put human happiness and social justice ahead of organ function.
These presenters outlined how one million dollars could augment wellness, help both staff and patients connect with nature, promote physical and mental therapy, and prevent patients from deteriorating using intelligence: both artificial and old-fashioned. The first speaker offered a better plan for mitigating carbon than that of most politicians. The last speaker and titular winner (aka the ‘first amongst equals’) did not want a game-changer but rather a name-changer. He wanted formal recognition of the unavoidable reality of death by changing the sign on the Intensive Care Unit (ICU) to the Intensive Care and Palliation Unit (ICPU). Before you gasp, this was step one in a comprehensive plan to save both lives and deaths. Of course, it would cost more to roll out these ideas nationwide, but each could fuel its own quiet revolution.
So, what does a revolution born in Canada look like? Presumably it starts with a polite conversation: maybe over tea. Clearly, money is needed when the problem is insufficient “stuff.” However, money is mere paper when it comes to many things that matter: connection, communication, and caring. It costs nothing to be graceful, namely to work out what you can give rather than what you must get. It costs nothing to make an extra effort, to bring your best self to work, or to start a dialogue. I think we could also chat about whether our healthcare “gimme-more” mantra simply mirrors our first world society. For example, there are apparently already an estimated 300,000 items in the average North American home and its size has trebled over the past half century. Three percent of the world’s children live in North America, but reportedly receive 40% of the world’s toys.
Philanthropy is wonderful and should be mightily encouraged; but in all of us, not just the uber rich. Give what you can whether it’s money, time, or empathy. Moreover, before you stick your healthcare hand out make sure you need it and deserve it. This Canadian has sung along to “if I had a million dollars” many times. It’s a great ditty but is ultimately about getting not giving. Just as I plan to be more cautious about gratuitously celebrating Canadian achievements, perhaps I could update the self-centered song that plays in my head.
Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada.
Competing interests: None declared.