Abstracts
Résumé
L’auteur, dans l'article qui suit, tente de montrer dans quel sens s'est exprimée l'évolution sociale du Québec et comment ces nouvelles données communautaires redéfinissent l'exercice de la profession médicale chez nous. Il pose aussi quelques problèmes auxquels le corps médical doit faire face à l'heure actuelle.
Abstract
The Quebec scene has undergone many important transformations since the beginning of the century. A rural way of life gave way to the emergence of an urbanized one. This was characterized by a shifting of the population from rural areas to metropolitan centers. The industrialization and urbanization movements came late and without a real participation on our part. They presented a challenge to our old cultural patterns marked by social and moral authoritarianism, non-interventionism, and liberalism as a way of thinking in the realm of public policy. Without having completely discarded a traditional way of thinking, we are awaking to the requirements of a « concerted » economy and this is where the notion of progress takes a true character of actuality. From an economic and technological stand point progress has been made, but we want to draw attention on social progress, that is, a more generalized and better equalized access for all groups to material well-being, knowledge, and maximum happiness.
Those social transformations lead to question preconceived ideas in the fields of manpower policies, income distribution, professional organizations, labour-management relations and public policy.
PROFESSIONAL ASSOCIATIONS AND THE « NEW SOCIETY »
Where do our professional associations fit in this « new society » ? We want to deal with this issue before looking at the specific case of the medical profession and socialization of medecine.
In a socialized context, economic partners and functional groupings cannot act according to their sole interests but must structure themselves mentally and organically in order to satisfy as fully as possible the requirements of community policies whose formulation will have been a product of their democratic contribution.
Professional associations as any other intermediary bodies are, by their very nature, « service agencies » as well as « pressure groups ». Therefore, in a socialized context, the order of priority should not be reversed. Those associations should keep on behaving as service agencies first: and as pressure groups, second.
THE MEDICAL PROFESSION IN A SOCIALIZED REGIME
Traditionally, the medical profession has been exercized on a « private basis ». At that time, social security was not existing, and the market for medical cares not regulated. Most of the elements that we use to find in a free enterprise system were present in the exercice of the medical profession. Physicians use to decide the type and quality of services rendered as well as the price to be asked for. This laissez-faire period characterized the exercice of the medical profession. Social assistance, workmen's compensation legislations have been passed without threatening the concept and practice of « liberal medicine ».
However, with the development of scientific knowledge, medical specialties came to the fore. A diversity of interest and even certain oppositions appeared within the medical body. The birth and organization of hospitals and medical centers facilitated the access to medical specialities and created conditions for the exercice of the profession completely different from those previously existing. A creeping change took place in the status of the physician toward the exercice of his profession, the hospital-employer and the client.
HEALTH INSURANCE AND THE MEDICAL PROFESSION
Health insurance is not a new expression. European and North American trade unions, political reformist parties made numerous attempts to get health legislation enacted. In Canada, a Royal Commission was instituted and its report on social security, the Marsh Report, came out in 1943. The members of medical associations showed a great amount of resistence to the possible enacting of those « equalizing » measures. This was also the case for other associations which considered any government attempt to nationalize public services as a threat to the free enterprise system.
However, the economic, structural, and social transformations, the requirements of economic growth, the necessity to live up to this huge aspiration to a shared well-being, the unavoidable socialization of functions, and the State being more and more conscious of its role in such a context have changed the dimensions of the problem. What was a private service under a liberal regime becomes a public service under a socialized one; what was left to private initiative falls now in the realm of government initiative. Manpower, education, and health followed this line of development. With hospitalization insurance and, pretty soon, health insurance, health becomes a public service. Consequently, hospitalization, which was previously a charitable and private institution, is now a public service, the same reasoning applies also to medical cares. The Province of Quebec was sensitive to those transformations and installed a regime of hospitalization insurance. This scheme arose certain problems.
The Number of Physicians
Facing a growing demand for medical cares, professional associations in collaboration with universities must deploy all necessary efforts to provide the staff of physicians needed, while saveguarding the requirements of competence and integrity.
Medical Unionism
We acknowledge the existence of professional unions of specialists which have lately formed a federation. It is our opinion that trade unionism is the only way to make functional and economic interests prevail, vis-à-vis the State, hospital institutions, and private systems of insurance. The negotiation of working conditions must be done by functional groups other than the corporation itself.
The Medical Profession and Governments
An important question is the nature of the relationships between the medical profession and public powers under a universal health insurance plan instituted by the State. The medical profession must define its attitudes toward the socialization of medical cares, since it is directly involved in the fixation of earning and working condition of specialists doing their work within hospitals and general practicians working in the field.
The medical profession must acknowledge the impossibility to decide alone on the whole range of problems that we described above. It must accept indirect government intervention in the exercice of the profession. It must accept to discuss objectively by the medium of collective bargaining. The medical profession must avoid to mix practical rules governing the exercice of the profession with doctrinal or philosophical stands in its relationships with public powers and the community as a whole.
To bargain in a « concerted economy » involves different issues : to participate, on one hand; to contest, on the other. As any other intermediary bodies, the medical profession must participate in a worthwhile manner at the policy-formulation stage. Once decisions are made by the State, the medical profession must be able to contest them, whenever it is believed that vital interests bearing on medical practice risk of being destroyed.
A Legislation Pertaining to Professional Activity
Physicians and their representatives are invited to develop a new kind of labour Iaw, already known in France and called « un droit de l'activité professionnelle ». For the time being, medical associations are borrowing from industry and labor-management relations the techniques of collective bargaining. But such a transfer of techniques and institutions is not sufficient. We need the development of a body of legislation adapted to the requirements of a new situation in which new kinds of organizations are working.
Necessity of Social Education
Since the medical profession has to assume new responsabilities, it must stress the importance of social education for its members. Physicians and other professionals have been accused of living in an ivory tower, far from the emerging reality which surrounds them. The indictment is often well founded. Therefore, it is getting urgent for the medical profession to increase its knowledge of social mechanisms at play within our modem society.