General practice, candy, and the veil of ignorance

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My grandfather grew up farming and hunting for sustenance in a wild, dangerous but also achingly beautiful corner of Africa long before the age of telecommunication. He left precious and indelible footprints in my heart and memory banks when he died at the turn of this century.

As little children we often wheedled stories out of him about the ‘old days’. One of his favourite stories was about an incident when he was only six years old. His father had brought a handful of assorted candies home one memorable night for him and his younger brother to share. This was an unprecedented event and created huge excitement.

As the older brother, my grandfather was assigned responsibility for dividing the sweets into two equal piles. My grandfather recounted how he purposefully selected out the most delicious and eye-catching candies for what he intended to be his share. But his reaching hand was stayed by the firm voice of his dad: ‘Stop Carl. You divided the sweets, so it is fair that your brother gets to choose which portion he wants’.

At this point in the story my grandfather would give a little jerk, clap his hands together and make a loud grunting noise of unmistakable regret that seemed amplified by the passage of many years.

My grandfather learnt a valuable lesson that night that stayed with him for the rest of his life. I believe the lesson is important enough that it should be applied by government officials and healthcare policy makers when they decide how general practice and other healthcare services are funded in Australia.

The shortcomings of our existing Medicare ‘fee-for-service’ funding model for general practice are well known. It is a relatively simple and easy system to administer, but the inherent simplicity also creates barriers to effectively deliver high quality care for our increasingly complex, multimorbid and ageing population.

In response, there have been proposals to develop and implement more suitable and sustainable funding models. The primary alternative so far has been capitation – a system that provides a fixed annual financial fee for each patient enrolled in a practice. Other funding models have also been proposed, including salaried positions and blended models.

Every model has supporters and detractors, but objective, reliable evidence remains scant. Selecting a fair funding model is therefore incredibly challenging. It is a decision that affects every single one of us in Australia, from general practice clinicians and staff, through secondary care organisations to consumers and communities.

I believe the ‘veil of ignorance’ provides us with a practical and powerful method to explore the moral and social issues wrapped up in this decision. In 1971 the philosopher John Rawls proposed the following thought experiment for anyone making important decisions: imagine there is a veil between you and the world – or the system – you are intending to change. Once you have made your decisions, you must pass through the veil and accept any randomly assigned position in the system you have selected, serve in that role and bear the associated consequences.

What would general practice look like through a veil of ignorance? What funding model would be preferred if personal considerations were irrelevant and any of us could play any part?

The concept of a ‘veil of ignorance’ is of course not new. It has been around in different variations for centuries, e.g. Immanuel Kant’s universalizability and the Golden Rule of treating others as you want to be treated. My grandfather’s story reminded me that, whether we are dividing a handful of candy or a healthcare budget, draping a veil of ignorance can often help us make better choices.

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