Priorities

In the 1960s when we lived in Edinburgh, my Canadian-American friend Kerr White sent Marie McCormick, a very bright medical student from Johns Hopkins University medical school, to spend a summer term elective period with me. Marie later became a distinguished pediatrician. The main task he gave her for her summer elective was to find out what criteria were used in Scotland to set priorities for the use of scarce and costly renal dialysis services. It was an epidemiological approach to an ethical problem, priority-setting in the allocation of very scarce and very costly services The question of setting priorities for renal dialysis and Marie's youthful enthusiasm led me to become associated for a while with a select committee of the Scottish National Health Services that had the heavy responsibility of deciding which patients in renal failure would get access to renal dialysis and the chance to live a little longer, and who on the contrary would not get access to dialysis and therefore would be allowed to die untreated. Put like this, it sounds cold-hearted, inhumane, the opposite of what good medical practice is supposed to be. On the contrary, it is the very highest quality medical care, to use reason rather than happenstance, wealth, emotion to decide how best to allocate extremely costly equipment and a skilled team of very highly specialized physicians and the technical experts responsible for running and maintaining the equipment, performing tests and titrating biochemical variables. I can't remember all the details but I do remember that in the early and middle 1960s the existing renal dialysis services in Scotland could meet the needs of only about one in every nine or ten of the theoretically eligible patients. As best we could determine at the time the situation was much the same in other wealthy nations, except the USA, where the deciding factor was (and still is) wealth: those who could afford to pay got dialysis, even if they suffered from a terminal condition like diabetic renal failure. In Scotland then, and in other enlightened nations then and since, decisions about allocation of scarce resources and the expertise of highly specialized professional staff were based as far as feasible on reproducible scientific evidence. It is a variation on the theme of triage, the system used to decide whom to treat first (and whom to allow to die quietly) in a major disaster with mass casualties.

I remember and think about Marie McCormick's work on renal dialysis in Scotland in the 1960s when I see the range of sophisticated equipment and devices, and reflect on our good fortune to have such a plentiful supply of skilled expert professionals caring for Wendy. Is there much priority-setting, or is access to the top quality care we have had, determined by my 'rank' or my knowledge of the system? I don't think it's either really; I think we are just fortunate to live in a city that is fairly well supplied with excellent professional people in all the branches of the Canadian health care system, and a reasonable supply of all the specialized devices and equipment that we have needed. Once again, I'm thankful for the Canadian health care system and all the services and skilled staff it employs.