To what degree is private health care a service industry?
I recently had a case of a perimenopausal woman in her mid 50’s whose chief concern was that she wanted to begin lactating. She had never given birth, nor was it her intension to serve as a wet nurse. She simply had a strong conviction that to lactate, for her, would be a profoundly healing experience both spiritually and physically. She suffers from a chronic incurable illness and so the objective for me has always been to maximize her quality of life. As you might imagine, her request raised some controversy as to the role of naturopathic medicine in a private setting. The question is: To what extent is private healthcare a service industry?
I have to admit I have struggled with defining the role of naturopathic doctors in a country where socialized medicine prevails. I have previously discussed the issue of private and public medicine in my article entitled “Public vs. Private Health Care: Investing in the Value of Time”.
The distinction between physician and service provider can be challenging to clarify. On one hand, naturopathic doctors provide treatment to sick patients and we have standards and responsibilities that are comparable to those of conventional medical practitioners. And so it might seem appropriate that we conduct ourselves in a similar manner to medical doctors. However, because our patients often reimburse us directly, we are freed from the responsibility shouldered by medical doctors to manage public resources. In this respect, we also resemble health service providers such as a dentist, a chiropractor, or a councillor.
There are many ways in which health professionals provide services that improve quality of life above and beyond treating or preventing pathology. Numerous allied health professional such as psychologists, social workers and occupational therapists provide publicly funded services which improve quality of life through counselling, social interventions and orthopaedic aids - to name a few. Even within the public system we see examples of procedures deemed non-essential, like elective cosmetic surgeries that are made available to patients at their own expense. And so if we endorse the pursuit of improving quality of life, where do we draw the line between treatment and service? How do we decide what we will and won’t help people do?
Certainly there are situations when patients desire assistance for unsafe or unhealthy purposes; like the young girl with a body dysmorphic disorder seeking weight loss, or the narcotics addict seeking another prescription for his “back pain”. In these cases most would choose not to provide the requested service because it directly conflicts with our role as care providers and our oath to “First do no harm”. Perhaps we ought to adopt to a paternalist approach to protect our patients from harming themselves by making uninformed decisions. After all, aren’t we the experts in human health? Perhaps, but most patients are paying for advice not protection. And then there are situations when the service requested does not overtly conflict with our role as caregivers. One example might include running costly lab tests (at the patients expense) which may not be clinically indicated, but offer the patient some information or assurance about their health. In these cases shouldn’t our role be to educate and advise patients by helping them make the decisions that will lead to the realization of their goals - regardless of how misdirected we might think they are. Isn’t that the spirit of informed consent and patient autonomy?
Granted, doctors need autonomy as well. It is equally unethical to expect a doctor who is morally opposed to abortion to perform a D & C. And so doctors should not be expected to help someone take actions that they personally deem unsafe or unethical. And so, with the exception of certain acts (such as suicide) which we deem as a society are impermissible, I believe people deserve the right to make their own decisions about their health. And if a doctor or any other healthcare service provider is authorized and willing to assist them, they should be permitted to do so.
I suppose by now you can tell my position in the debate on my non-lactating patient. In her case I believe that the health benefits of attempting to lactate may possibly outweigh the potential risks. Even if they didn't, I’d like to think I would still respect her autonomy in making an informed decision. But I’m a new practitioner and an admitted idealist, perhaps in time I will see things differently. Moral soap-boxes aside, I’d like to think that the titles of “patient”, “service provider”, “caregiver”, “therapist” and yes even “doctor” are just different ways of recognizing a relationship between to autonomous persons who have agreed to work together for a common goal.