Exec.Summ. Are there positive inducements which can be offered people to reduce demands on the health care system? I think so. They are not consistent with the “Western values” referred to below. They are consistent with very pervasive practices in Western society.
===============
 I first attempted to raise the issue of rationing health care in Ontario with the then Minister of Health in 1986. I was [of course?] ignored. Between the work of Daniel Callahan, Gov. Lamm and others there is really little that need be said as regards the economic aspects. Gov. Lamm’s approach either makes obvious sense or it is simply morally wrong as Dr. Mitteler finds it.
 As a hospital chaplain I have seen instance after instance in which health care providers make decisions about who is worthy [in terms of anticipated benefits? “Morally—in terms of the patient’s life history?” “Morally—in terms of some value I the health care provider hold?”-- of what treatment The involvement of patients/substitute decision makers varies from extensive to none. Covertness of the process guarantees arbitrariness.
he one [still] edifying aspect of all this here in Canada is that ability to pay is not a consideration. As Governor Lamm noted last year, in Canada, there is growing awareness that no publicly-funded health care system can provide everything that someone would find medically beneficial. One of the key figures in the establishment of the Canadian publicly-funded hospital & physician-care system in the late 1960’s recently commented that it was never contemplated that this system would provide for the costs of chronic & long-term care. The politics of openly rationing health care is, however, still impossible.
 My work as a chaplain in Long Term Care Facilities heavily influences my perspective.
 The question for me is whether there are any places “outside the box”. Which box? “The discussions regarding health care cost containment were conducted on a level that did not violate or offend the value system of Western society, in which all individuals’ lives are presumed to be equally important.”
 --Osgoode, Nancy J., Barbara A. Brant & Aaron Lipman Suicide Among the Elderly in Long-Term Care Facilities NY: Greenwood Press, 1991,p.157
 I agree that making decisions about the quality of life of others sets us up for Hitler’s approach to what to do with socially useless human material. So, as I say, the problem is one of societal attitudes. Most of us do not regard life as a cycle. We see it as something linear [which might just keep going]. The former is the outlook found in most traditional cultures. Paradoxically, our new technological capabilities may warrant a return to such an outlook. This of course is not a solution to the crisis of health care costs in the time-frame required.
 Anyone interested in discussing short-term approaches to inducing people to reduce demands on the health & long-term care systems? jwouk@ottawahospital.on.ca