Guest Writer Profile: Jan Kluthe Jan Kluthe is Planning Coordinator with the David Thompson Health Region's Corporate Planning Department. She graduated with distinction with a B.Sc. Nursing (University of Alberta, 1985) and recently completed a Master of Public Health, specialization in health policy and management (University of Alberta, 2001). Jan has experience in numerous areas of health care including public health, home care, acute care, continuing care, health promotion, research and evaluation, and currently in planning and process improvement. She is a graduate of the Alberta Heritage Foundation for medical Research's two-year SEARCH program that focused on evidence to support decision making. Jan's areas of interest include humanity, ethics, planning, and health and social policy.

Challenges in any review of the health care system include ensuring that the recommendations for change are evidence-based and ethically justified, and that the values and principles of Canadians are considered. Equity and equality are two central values of Canadians and are among the core ethical values that form the foundation of the current publicly funded health care system in Canada. This is indicated often and in various places such as the Royal Commission of Justice Emmett Hall in 1964 (Commissioner E. Hall, 1964-65) where he called for a universal medicare scheme "available to all Canadians... whatever their financial resources."

But what are equity and equality? What do these terms mean? And how do we know whether suggested changes to the health care system affect these values, either by moving towards or away from them? For, according to Yeo (1993). "the issue is not whether to make trade-off decisions but how to make them, and according to what values criteria."

In this article I wish to explore the meanings of these two crucial and yet readily confused--and confusing--terms. As well, I will suggest what it might mean to make these values part of a discussion on changes to the health care system.

Equity and Equality

The terms equity and equality are often used interchangeably, yet they represent quite different, if related, concepts. As defined by Webster's New World Dictionary (1988), equity is fairness; impartiality; justice; anything that is fair or equitable. Equality, on the other hand, is defined as the state or instance of being equal. This in turn is defined as having the same rights, privileges, ability, rank, etc., or of being the same quantity, size, number, value, degree, intensity, quality, etc.

To achieve equality in distributing a given resource, everyone would be provided with an identical amount of it. So, for example, if we were interested in dividing a pie equally, we would cut the pie such that every recipient would get exactly the same size of slice. Depending upon how important this was, we may be interested in ensuring that everyone got the same amount of filling, crust, topping, etc.

If, on the other hand, we were interested in cutting the pie such that we were aiming for equity in distribution, then things would become more complicated. We would need a richer understanding of what it means to be the most fair. And this understanding would depend on what we take to be relevant criteria for fairness.

Possible criteria in this example might include: hunger, who would benefit most from receiving the pie, effort or merit in making the pie, effort or merit in acquiring the resources to buy the ingredients for the pie, what the favorite pie parts of the various recipients are, who has been the best behaved of the recipients, and so forth. We may still cut the pie into equal sized slices, but it would only be equitable once we have agreed on the relevant criteria for a fair distribution and once we have determined that all of the prospective recipients are equally deserving of the pie based on the selected criteria.

Equity then, may involve distributing a resource equally or unequally, depending upon what the relevant criteria are for what fairness requires in a given situation.

Equity and Equality in Health Care

Moving to the real life example of health care, the current structure of health care funding in Canada (considering the portion that is publicly rather than privately funded) is based on the principle of equity.

Canada, at the federal level, has a progressive taxation system as do the majority of the Canadian provinces. This means that individuals with a higher rate than their lower income counterparts. These resources are then used to fund public goods and programs such as the publicly funded health care system. For the most part, we as a society have decided that the most important criteria for distributing heath care resources within the system is medical need rather than, for example, how wealthy those who have need of the system are.

The system is equitable in that it involves a redistribution of resources, providing health care services to the whole population but funded from a larger percentage of the dollars of those who have increased income. In effect, those with higher incomes pay for the care of those who have lower incomes, but equal or greater need.

Caplan, Light and Daniels (1999) suggest that this redistribution is ethically justified. They advocate that a progressive federal income tax (as opposed to a flat tax) for funding a health care system is the most fair. They "start with the assumption that everyone is of equal value or worth and should be treated the same. Consequently, fair health care reforms would seek to reduce the differences in health and health care between groups. To accomplish the latter (reduce differences among groups), however, one must violate the former (treating everyone the same). The sick will need more resources than the healthy; so to reduce differences in health status, one must spend more on the sicker group."

Whether we agree with their assessment or not will depend on how we understand equality and equity. And how we understand equality and equity, or rather which of the two we tend to favour, may depend on how we see the world. For example, Stingl (1996) describes two different meanings of equality. One, originating in a libertarian view of society as developed by Nozick (1974), is where people are seen as self-interested agents, ultimately separate from one another, competing for scarce resources. On this view, society requires relationship of interchange requiring mutual agreement. The second view of society, called "liberal egalitarianism" is developed by Rawls (1971). It sees "society as a joint, cooperative venture, participation in which creates the sense of a greater, social good that grounds and gives context to everyone's own personal good." Rawls states that "[s]omething like this second notion of equality is arguably behind the single-tiered structure of the current U.S. health system is more nearly libertarian.

With the existence of varying definitions and interpretations of equity and equality it will be important for any review of the current health care system to clarify which definitions will be used for these principles.

Health System Changes

According to Yeo (1993), ethical analysis is disciplined inquiry about moral values and how they bear on issues and decisions. It involves making the values at stake in a given issue explicit and, in light of these values, articulating reasons for and against various alternatives for action.

It is important for any review of the health care system to determine a suitable ethical framework that not only includes guiding principles such as equity and equality, but also makes clear what they mean and how they are interpreted. One source for an ethical framework and guiding principles can be found in the Royal Commission on New Reproductive Technologies (1993).

Another valuable source that I wish to recommend can be found in "The Benchmarks of Fairness" developed by Caplan et al. (1999). The framework consists of ten scorable benchmarks of fairness and thirty detailed criteria to address the void of gauging how a given change would alter the equity or fairness of existing health care services. Although the framework was developed to identify the dimensions of fairness for the American health care system, it can be adapted for use in the Canadian health care system.

Conclusion

Equity and equality are important ethical principles and, as such, it is recommended that they be considered carefully during any deliberations about the future of the health care system in Canada. Any review process should include: articulation of how these terms are to be defined, exploration of how Canadians view these two principles, selection of an ethical framework to guide the process, and clear indication of how these principles fit within the framework adopted. Of course, it goes without saying that for any review to be meaningful, integrity must be central to this process.

References

Caplan, Ronald L., Light, Donald W., and Daniels, Norman. Benchmarks or Fairness: A Moral Framework for Assessing Equity. International Journal of Health Services. 1999. 29(4); 853-869.

Commissioner E. Hall. Canada, Report of the Royal Commission on Health Services. 1964-65. Queen's Printer, Ottawa.

Nozick, Robert. Anarchy, State, and Utopia. 1974. Basic Books; New York.

Rawls, John A. Theory of Justice. 1971. Harvard University Press; Cambridge.

Royal Commission on New Reproductive Technologies. Proceed With Care: Final Report. Government of Canada 1993. Chapter 3.

Stingl, Michael. Efficiency Versus Equality: Health Care Reform in Canada. Ed. Michael Stingl & Donna Wilson. 1996. Fernwood; Halifax.

Webster's New World Dictionary, Third College Edition. 1988. Simon & Schuster, Inc.; New York.

Yeo, Michael. Ethics and Economics in Health Care Resource Allocation. 1993. Queen's University of Ottawa Economic Projects, Working Paper No. 98-07, University of Ottawa, Ottawa.

 

Announcements

PHEN, in conjunction with several partner organizations, will be hosting a major conference on the Ethics of Allocating Health Resources to take place April 10 to 12, 2003 in Banff, Alberta. For more information, please contact PHEN's Northern Alberta Office

The third offering of the distance education course Introduction to Bioethics, geared particularly towards busy and practicing health care providers and administrators in Alberta, will take place from January 13 to May 22, 2003. Deadline for registration is December 2, 2002. For more information and application forms, please visit our home page.

Rose Muto and Christina Matteott, summer research assistants working at the Network's Northern Alberta office, have returned to their academic pursuits. PHEN thanks them for their valuable contribution to the Network's activities and wishes them prosperity in their studies. The staff is very please that both Rose and Christina plan to continue their work with PHEN as volunteers.

Upcoming Conferences

• Health Law Institute: September 27-28, 2002 in Edmonton. Details at www.law.ualberta.ca/centres/hli/
  
  
  
• Canadian Bioethics Society: October 17-19, 2002 in Victoria, BC. Details at www.uvic.ca/cbs
  
  
• American Society for Bioethics and the Humanities: October 24-27, 2002 in Baltimore, Maryland. Details at www.asbh.org
  
  
• International Association of Bioethics: October 30 - November 3, 2002 in Brasilia, Brazil. Details at www.bioethicscongress.org.br.