About those waiting lists . . .

The article and commentary by Claudia Sanmartin and colleagues1^,2 outlining the challenges we face in deciphering the true meaning of waiting lists and their impact on patient care are important additions to the debate on the future of medicare in Canada. Physicians and their patients are often caught in a baffling waiting-list maze that results in a feeling that the health care system is dysfunctional.

The ethical underpinning of the concept of waiting lists deserves greater emphasis. In Canada, the notion of distributive justice has dominated the design of the health care system.3^,4 Lately there has been a leaning toward the ethical principle of autonomy, which has been paramount in the United States. Patients struggle with their own needs and not the needs of the general public, so it is understandable how the shift toward personal priorities can lead to the erroneous belief that private medicine can solve the public resource problem.5^,6

It will become increasingly difficult to defend medicare when premiers like Ralph Klein and Mike Harris, as well as the leaders of the Canadian Alliance party, use their political powers to undermine the public system. They will continue to find novel ways to insert private components into the system that agree with their political beliefs. For example, young physicians who now face substantial education-related debt because of government-mandated tuition increases will be less inclined to support a publicly funded system if better financial opportunities are available in the private realm.

Thus far, Canadians have chosen the ethical principle of distributive justice over that of autonomy as the foundation of their health care system. It will take a great deal of dedication and persistence from medicare's supporters to keep this foundation from crumbling.

A meaningful and accurate understanding of waiting lists that is transparent to physicians, patients and politicians is one important step in helping maintain our commitment to a system that has served Canadians so well for so long.