Classical liberalism emphasizes autonomy, individual freedom, and free markets. These ideas have fuelled centuries of wealth and prosperity.
Modern liberalism, in contrast, pursues central decision-making and equality of outcome. Despite similar names and obvious differences, neither type of liberalism provides arguments for everything patients need.
When classical liberalism fails in patient care, it creates space for modern liberalism. Modern liberalism then applies central decision-making, which creates inefficiency and bureaucracy. This, in turn, creates a call for efficiency, deregulation, and policy based on economic liberalism.
This seesaw creates a policy teeter-totter with each type of liberalism pumping furiously at either end.
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The failure of liberalism cannot be solved by more liberalism. Only a coalition of classical liberalism plus conservatism will allow Canada off the health policy teeter-totter.
How liberalism fails
Successful ideas explain reality and suggest solutions to life’s messiest problems. Political ideas fail when they do not reflect reality or cannot explain human experience.
Given liberalism’s dominance in Canadian politics, we should ask how it performs for patients. Does it make sense when patients need it most? Classical liberalism delivers advanced technology, therapeutics, and almost magical cures, but can it deliver care to patients?
Classical liberalism fails to fit patient care in two areas. First, it fails in trauma and acute care. Car crashes and strokes often create dependent, comatose patients. Free agents lose control, and agency passes to a third party.
An unconscious patient is not a rare or special case of information asymmetry, common in professional relationships. Unconsciousness is not a theoretical gap market thinking can overcome; it is an infinite and insuperable knowledge gap. And it occurs hundreds of times each day across Canada.
In an emergency, agency does not pass from patient to friends or family. It passes to emergency medical services, hospitals, doctors, nurses, and a host of others. The coordination required to guarantee a seamless net of tertiary care inevitably involves central authorities. Government monitors performance, upholds standards, and maintains order, even in health systems that embrace private care.
Liberalism’s second failure occurs with chronic disease. Chronic disease is more common than acute, impacts more people, and requires care over decades. In between visits for medical care, patients need help with everything from scheduling and transportation to buying groceries and changing cat litter. Even with extensive formal community care services, isolated patients struggle. Informal social supports often determine how long patients live independently.
Hospitals provide services and are filled with caring people, but institutions cannot care. Only individuals care for other individuals. Patients need connection to individuals inside the bonds of social obligation: friends, family ties, or social groups.
For people who become acutely incapacitated or chronically debilitated, classical liberals offer solutions like designating a power of attorney for care or making prior arrangements with friends and family to act on an individual’s behalf. But these good ideas sound less like classical liberalism and more like organic groups and social fabric found in conservatism.
These patients are depending not on large institutions but on something like Edmund Burke’s “little platoons,” which conservatives have always identified as the key to a healthy life.
Liberalism and medicare share a symbiotic relationship – each benefits the other. This is obvious for modern liberalism: medicare needs a big state, which requires the central decision-making favoured by modern liberals. But symbiosis also applies to classical liberalism.
In acute care, free agents need rescue – not rights, property, or the contracts liberalism provides. In an emergency, the only agent obligated to help is the same agent which sustains the liberal order (Hobbes’ Leviathan). Thus, maximizing liberal freedom creates a mandate for a robust welfare state to rescue individuals when they fall ill.
However, the symbiosis falters in community care. Individuals with chronic illness need connections liberalism cannot promote, and no state can provide.
Extrapolating government involvement
The need for central authority in acute, traumatic, and rare advanced treatments invites the same assumption for chronic care. If the sickest patients need government, shouldn’t government help with everyone else?
Framed this way, modern liberalism has led the discussion on medicare. With deference to central control, it assumes that the solution for the first failure of liberalism will solve the second also.
Conservatives find themselves in a similar bind. They support what works. If central control helps patients bleeding at the side of the road, why oppose it for non-acute and chronic care?
Too often, Canadian conservatives claim a “Tory touch” and the assumption that big state solutions are part of their true-blue identity. Or they suggest a dab of economic liberalism here, some tightened accountability there, but offer few ideas which reflect anything rooted in philosophical conservativism.
Some people reduce conservatism to nostalgia. Others paint it as protection of privilege, status, and power – a European conservatism. However, Canadian Anglo-American conservatism has too little history for robust nostalgia and no aristocracy to protect.
The historic alliance between classical liberals and conservatives also creates confusion.
Anglo-American conservatism is founded on an appreciation for traditional institutions, civil associations, and moral norms which have arisen over time. These time-tested ideas have been ratified by experience.
Where liberalism favours freedom over social obligation, conservatism sees social obligation as an inescapable fact of life (e.g., family). Classical liberals often assume aspects of conservatism, without explicit defence.
Conservatism takes a skeptical stance towards theoretical or grand ideas such as equality or social justice. Conservatism prefers facts and events – real things and real people. It seeks to improve what works, which means conservatives often support liberal or progressive policies.
Little platoons can happen by accident, but most do not survive without support. Everyone is born into a family, but it takes effort to keep one together. The state could make things easier.
For example, many families place relatives in long-term care because they have no other choice. The current policy environment makes life hard for families to keep grandma home. Could we reverse incentives so it becomes attractive and easy to keep grandma where she wants to be, at home with a family who loves her?
Every citizen needs the opportunity to be part of a social network of his own, regardless of how he defines it. But this will not happen without a policy environment that fosters the formation of those connections.
A conservative solution
If we won agreement to let grandma stay at home as long as possible, we would still face the policy teeter-totter. Classical liberals would seek aligned incentives, crisp key performance indicators, and clear lines of accountability, from the ground up. Modern liberals would want the same, from the top down. Classical liberals might offer incentives and tax breaks to keep grandma home; modern liberals might suggest more homecare or social services – each liberal pumping furiously.
Both kinds of liberals love modern theories of public management almost as much as they love drafting new policy. They both view social problems in generic terms – an ageing society, isolated seniors – instead of specific, local problems. Generic terms justify grand, one-size-fits-all policy solutions. Solving the specific needs of grandma’s living alone holds less appeal.
Conservatives worry more about creating new, bad policy than winning support by ‘fixing’ old issues with the latest management theories. Complex social problems mean trade-offs and imperfect solutions.
Conservatives would start with the (painfully) slow process of understanding the problem. Instead of discussing generic grandmas, we need to know more about grandma herself. Is she one person or three: an ambitious woman in her early 80s, a slightly confused one in her late 80s, or a demented lady with papery skin and chronic wounds in her mid-90s? Or none of these? One individual could be all three in the span of a few years.
We might start with issues facing young grandma(s). In her early 80s, grandma has the wits and plans of a younger person but not enough strength to see them through. She needs a bit of help, but not so much it impedes her style. She is too healthy for homecare but too poor to hire help. If she lets out a room in return for low rent and yard work, she might find herself worse off with OAS clawbacks on top of bigger grocery bills, blocked toilets, and the bother of having a renter around. She could barter material resources for required help, but government does not make it simple. Or she could take in family to help. But at her young-ish age, it might mean more nuisance than help. Of course, all these concerns would change by her late 80s.
A policy approach based on conservatism might look more like local, organic problem solving than grand, one-size-fits-all policy solutions. Conservatism starts from a view of society as a complex whole requiring long-term investments instead of quick returns based on annual budgets.
Conservatism plus classical liberalism
Little platoons are just one of many conservative ideas. Smart people should be able to use conservatism to suggest many other policy options.
This raises a bigger question. Aside from so-called “socially conservative” issues, why have so few conservative ideas been tabled in healthcare?
If not lack of knowledge, perhaps it reflects a lack of belief. Perhaps modern conservatives are mostly just classical liberals? Maybe most self-described conservatives are just liberals who lean right? Or perhaps conservatives and classical liberals have become competitors, each vying to dominate centre-right discourse, not working together as well as they might?
Medicare does not struggle for lack of ideas or funding. It struggles from funding thrown at the same tired ideas rooted in similar political traditions. Classical liberalism offers many good things, but it fails patients in important ways. Absent outside input, liberalism guarantees stasis in Canadian healthcare: a furious teeter-totter between two kinds of liberalism. A partnership with conservatism would help.
Shawn Whatley is a physician and author of the new book When Politics Comes Before Patients – Why and How Canadian Medicare is Failing. He is also a senior fellow at the Macdonald-Laurier Institute and a past president of the OMA.
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