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172 lines
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172 lines
8.6 KiB
Plaintext
Danielle Crittenden - Wall Street Journal - March 31, 1994
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(Ms. Crittenden recently moved back to her native Toronto)
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Recently I spoke to a friend who had given birth to her second
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child a week after I did in November. My child's birth was
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covered by private insurance in New York; my friend gave birth
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here, under Canada's much-lauded, state-funded, universal health
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care plan.
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"Did you have an epidural?" she asked suspiciously, referring to
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the local anesthetic injected into the lower spine, a common
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painkiller for childbirth.
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"Of course," I said (neither of us romanticize the pain of
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"natural" labor). "It was wonderful. My husband and I played
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Scrabble in the birthing room right up until I had to push. I
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won," I added.
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A cold silence.
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"How did yours go?" I asked.
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"It was awful," she said bitterly. "When I got to the hospital, I
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asked for an epidural. The nurse said I had to wait - there were
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three people ahead of me. Soon, I was feeling sick with pain. The
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nurse told me to take a hot shower. I couldn't stand it anymore,
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and begged for the anesthetic. It still wasn't my turn. I was
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rocking back and forth in agony. Then the doctor arrived and said
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the baby was coming out and it was too late for anything.
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Afterward he apologized o me - he said I looked in terrible pain
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and it was horrible to watch."
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It seemed astonishing to me, listening to my friend's story, that
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in late 20th century North America a woman would have to give
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birth the old-fashioned way - in pain. It's true incidents like
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this do sometimes occur in the U.S., yet in Ontario - Canada's
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richest and most populous province - government control of
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medicine has made the exceptional the norm.
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My friend, who is an editor at a national magazine and married to
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a partner in a major law firm, give birth at St. Michael's, a
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bustling central Toronto hospital. The hospital's head of
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anesthesia confirms that from 4 P.M. to 8 A.M., as well as on
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weekends and holidays, there is only one anesthetist on duty for
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the entire hospital; for traffic-accident and burn victims,
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everyone. If he's busy, tough luck.
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St. Michael's isn't unique, either. I checked with other large
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hospitals in the city. Few had more than a single anesthetist on
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duty off-hours. At North York General, in the midst of Toronto's
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most affluent suburbs, 3,500 babies are born a year, 60% of them
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to women who request epidurals - and there is still only one
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anesthetist on duty off-hours.
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Outside of Toronto, the situation is even worse. Ontario's
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socialist government, desperately seeking to control its runaway
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health budget, has announced that epidurals will no longer be
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available to women in Thunder Bay, a community of 125,000 in the
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northwest of the province. Thunder Bay women needn't feel picked
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on. According to Richard Johnston, a spokesman for the Ontario
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Medical Association, the availability of epidurals is sporadic
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everywhere outside Toronto, because few small hospitals have the
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budget for anesthetists trained to give epidurals, especially
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during off-hours. Many women end up going to their general
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practitioners for delivery and doing it "naturally," whether they
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like it or not.
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Apologists for the Canadian health system blame greedy doctors
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for its chronic shortages and queues. But an Ontario doctor
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receives only US$100 to administer an epidural. His U.S.
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counterpart usually collects about US$1,000 (a figure that,
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unlike the Canadian, takes into account overhead and equipment).
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Epidurals are vanishing from Ontario, not because doctors are
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overpaid but because hospitals' fees per birth are capped at very
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low rates by a debt-burdened government. And, as many argue would
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happen under the Clinton health plan, it is illegal for either
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the doctor or the hospital to charge even willing patients more
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than the state-prescribed fee.
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The result? As Dr. Johnston says: "In the case of an anesthetist
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trained to give epidurals, it is not lucrative for him to offer
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his services all night. Why bother staying up, if you don't get
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paid extra for it?"
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Some American women have already gotten a whiff of the cruelties
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of Canadian medicine. In California, the Midwest, and Florida,
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according to Nancy Oriol, director of obstetric anesthesia at
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Beth Israel Hospital in Boston, some large HMOs refuse to pay for
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epidurals unless a patient has a medical condition thought to
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warrant it, such as a history of heart disease. And of course it
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is the intention of the Clinton health plan to drive ever large
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numbers of Americans into HMOs.
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My friend did have one choice that the users of HMOs do not - the
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freedom to choose her own doctor. But her choice was an empty
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one. For while she might pick an obstetrician, she had no way to
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be sure that he would in the end deliver her baby. Most Canadian
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obstetricians now work in groups, and a patient gets whichever of
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them happens to be on call at the time she goes into labor, or
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the intern on duty at the hospital (again, why bother to work
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late ...). Further, few Canadian doctors can afford to have
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ultrasound machines or other sophisticated machinery in their
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offices. Those tests have to be booked weeks in advance.
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My New York doctor, on the other hand, was there for me at any
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hour, even for a false labor at 2 A.M., because he is an
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old-style fee-for-service man. He also had an ultrasound in his
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examining room. In the end, my friend's baby was delivered by her
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family GP, because he promised to be present.
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Pregnant women, of course, are not the only Canadians suffering
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as provinces across the country seek to hold down health care
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costs. Americans are by now familiar with tales of Canadians
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queuing for heart bypasses and chemotherapy, or crossing the
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border for surgery. But what my friend's nasty experience reveals
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is that the system can no longer cope with an event as
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straightforward as birth. It is as if medical practice in Canada
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is reeling backward in time; in the case of birth, as much as a
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century.
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As part of this drive toward ever more primitive medicine, the
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Ontario government has set up three free-standing "birth
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centers," staffed by midwives. It is hoped that these centers, so
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much less costly to run than high-tech maternity wards, will
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attract "low-risk" pregnant women away from hospitals. Midwifery
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became a licensed profession in Ontario last year. These
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graduates of a three-year community college program will earn, on
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average, as much as $300 more per birth than obstetricians (who
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are paid $250 per delivery, and $18 per pre- and post-natal
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visit). The government has committed $8 million to the program.
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The ministry of health claims that its sudden munificence toward
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midwives is all the in the spirit of promoting "choice" for
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women. But given the difficulty women who do not want to suffer
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pain in childbirth face in exercising their right of choice, the
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gesture smacks of cynicism. It is health bureaucrats who are
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making the real choices. They have decided that epidurals are an
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"elective," even an extravagance, and that women who anticipate
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normal labors should have their babies without anesthesia, and
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better still, in someplace other than a costly hospital ward.
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You might expect that Ontario's anti-anesthetic policy would face
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charges of sexism. No one is suggesting, for instance, that men
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have hernia surgery without painkillers, under the knife of a
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"caring professional" who did not graduate from med school. When
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the American College of Obstetricians and Gynecologists last year
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found out that some U.S. insurers were refusing to pay for
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epidurals, they issued a report pointing out "there is no other
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circumstance where it is considered acceptable for a person to
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experience severe pain amenable to safe intervention while under
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a physician's care."
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But in Canada, the very feminist groups who ought to be outraged
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by the policy have, in fact, lobbied for it. These organizations
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have long complained about the male-dominated medical profession,
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its insistence on delivering babies in sterile hospital
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facilities, it enthusiasm for technology. One of the most
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important local advocacy groups is even proposing that five
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maternity wards in Toronto be shut down once the midwife program
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is up and running.
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A free-market health system, including one with HMOs, might not
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include insured epidurals; but it might create a relatively
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undistorted market in which people are to purchase this procedure
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themselves. A health system that is run by politicians is,
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however, subject to political pressure. This is especially true
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when a group's ideologic agenda coincides with the government's
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need to save money. In this instance, it actually puts women and
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their babies in the sort of danger and pain they have not known
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since their great-grandmother's day.
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