endoscopy care, who is also able to look after the sensitive and expensive equipment. The pathologist should be adequately trained in the interpretation of endoscopically obtained gastrointestinal biopsies. A full-time radiologist should be available during certain endoscopic procedures and for the correlation of endoscopic and radiologic findings. In addition, the principle of peer review should apply to endoscopic procedures as it applies to other areas of medical practice. Unless these criteria are fully met by the institution, its staff should not perform gastrointestinal endoscopy. How should these recommendations
be enforced? Special licensing for gastrointestinal endoscopy would be impractical at present. It is hoped, however, that the credentials and audit committees of the institutions where gastrointestinal endoscopy is performed will take their jobs seriously to prevent inappropriate use of gastrointestinal endoscopy by inadequately trained endoscopists. For institutions that are interested in monitoring and accrediting their endoscopists, the full report of the committee on endoscopy of the Canadian Association of Gastroenterology is available from the office of the secretary of the association (Dr. Ralph Warren, St. Michael's Hospital,
30 Bond St., Toronto, ON M5B 1W8). We hope that the present warning will be taken seriously by those responsible for the quality of care in their hospitals, and that the beast will disappear from the Canadian scene, leaving us with the well deserved boon that the advances in techniques of fiberoptic endoscopy should bring to Canadian patients. We hope it is not too late. R.R. GILLIEs, MD President Canadian Association of Gastroenterology BERNARD PERRY, MD
President-elect Canadian Association of Gastroenterology IVAN T. BacK, MD Chairman, endoscopy committee Canadian Association of Gastroenterology
Hurnan rights in personal health care In Canada, where sophisticated medical care is available to all, it is generally accepted that health care is a right rather than a privilege. Paradoxically, this very acceptance means that few of us have to ask the fundamental question of what constitutes an individual's rights regarding personal health care. To which of the multiplicity of medical services should a person have an unquestionable and inalienable right? This question is more pertinent in underdeveloped and developing countries than in Canada, but it is still of value to Canadians to define human rights in personal health care: when technologic advances compel us to define essential concepts such as life and death it is equally necessary to elucidate the intangibles of health. More than half the world's population lack modern health care,1 and King2 has made the challenging statement that "nowhere do we fail more dismally to apply what we already know for the good of our fellows than in the provision of health care". Against this statement one must set the ideal that no individual should be denied the right to adequate personal health care; one then realizes how much must be done before the principle that each person has a right to personal health care can be upheld. But first one must define minimum human rights in health. King, from his viewpoint in Indonesia, has attempted to define rights to personal health care in the following manner. Each person is entitled to at least some of the many diagnostic and
therapeutic interventions that characterize medical care. These interventions can be ranked from low to high on a scale that encompasses basic and sophisticated procedures - from testing for urinary protein and suturing of a wound at one end, to radioimmunoassay procedures and heart transplantation at the other. Also, some of these interventions are associated: a hospital, however simple and poorly equipped, can offer more than a single service. Good medicine, however, is more than a catalogue of interventions; knowledge, effective application of this knowledge and kindness are also important. King puts this all together in a "health care package", which he defines as "an integrated set of components assisting the application of a particular group of interventions for the improvement of health care under specific socioeconomic conditions". Each package is directed, simplistically perhaps, towards treatment of a specific problem; each comprises not only specific information but also educational objectives for health professionals, teaching aids, evaluative methods and some measure of its epidemiologic effect. King has been concerned primarily with child care, and in Indonesia he has designed health care packages, for example, for treatment of the dehydrated child and the child with diarrhea. In terms of human rights, would his concept be useful in Canada? A key consideration is King's view that health care packages are both an approach to defining rights in health
590 CMA JOURNAL/APRIL 3, 1976/VOL. 114
care and a way of implementing them. Consider two examples: the case of a pregnant woman at term in a developing country and that of another woman in Canada. As a matter of human rights, would not access to an obstetrici.in capable of performing a cesarean section be considered basic for both women? Certainly few would disagree, but in Canada one must go further: as a matter of human rights a woman should have access also to a competent anesthetist who can, for example, perform endotracheal intubation skilfully and rapidly. Human rights in health for Canadians are in part determined by the standard of health care, in such a way that a pregnant woman should have available to her a number of health care packages, just one of which is safe anesthesia. For Canadians health care packaging is a concept that perhaps has administrative and political connotations, but it could be useful in evaluating the adequacy of health care, and its greatest use might well lie in stimulating us to analyse component problems in the entire health care delivery system, particularly primary care and the training of physicians. DAYm A.E. SHEPHARD References 1. BRYANT 3: Health and the Developing World, Ithaca, NY, Cornell University, 1969 2. KING M: Personal health care: the quest for a human right, in Human Rights in Health, Ciba Foundation Symposium 23 (new series), Amsterdam, Associated Scientific Publishers, 1974
be enforced? Special licensing for gastrointestinal endoscopy would be impractical at present. It is hoped, however, that the credentials and audit committees of the institutions where gastrointestinal endoscopy is performed will take their jobs seriously to prevent inappropriate use of gastrointestinal endoscopy by inadequately trained endoscopists. For institutions that are interested in monitoring and accrediting their endoscopists, the full report of the committee on endoscopy of the Canadian Association of Gastroenterology is available from the office of the secretary of the association (Dr. Ralph Warren, St. Michael's Hospital,
30 Bond St., Toronto, ON M5B 1W8). We hope that the present warning will be taken seriously by those responsible for the quality of care in their hospitals, and that the beast will disappear from the Canadian scene, leaving us with the well deserved boon that the advances in techniques of fiberoptic endoscopy should bring to Canadian patients. We hope it is not too late. R.R. GILLIEs, MD President Canadian Association of Gastroenterology BERNARD PERRY, MD
President-elect Canadian Association of Gastroenterology IVAN T. BacK, MD Chairman, endoscopy committee Canadian Association of Gastroenterology
Hurnan rights in personal health care In Canada, where sophisticated medical care is available to all, it is generally accepted that health care is a right rather than a privilege. Paradoxically, this very acceptance means that few of us have to ask the fundamental question of what constitutes an individual's rights regarding personal health care. To which of the multiplicity of medical services should a person have an unquestionable and inalienable right? This question is more pertinent in underdeveloped and developing countries than in Canada, but it is still of value to Canadians to define human rights in personal health care: when technologic advances compel us to define essential concepts such as life and death it is equally necessary to elucidate the intangibles of health. More than half the world's population lack modern health care,1 and King2 has made the challenging statement that "nowhere do we fail more dismally to apply what we already know for the good of our fellows than in the provision of health care". Against this statement one must set the ideal that no individual should be denied the right to adequate personal health care; one then realizes how much must be done before the principle that each person has a right to personal health care can be upheld. But first one must define minimum human rights in health. King, from his viewpoint in Indonesia, has attempted to define rights to personal health care in the following manner. Each person is entitled to at least some of the many diagnostic and
therapeutic interventions that characterize medical care. These interventions can be ranked from low to high on a scale that encompasses basic and sophisticated procedures - from testing for urinary protein and suturing of a wound at one end, to radioimmunoassay procedures and heart transplantation at the other. Also, some of these interventions are associated: a hospital, however simple and poorly equipped, can offer more than a single service. Good medicine, however, is more than a catalogue of interventions; knowledge, effective application of this knowledge and kindness are also important. King puts this all together in a "health care package", which he defines as "an integrated set of components assisting the application of a particular group of interventions for the improvement of health care under specific socioeconomic conditions". Each package is directed, simplistically perhaps, towards treatment of a specific problem; each comprises not only specific information but also educational objectives for health professionals, teaching aids, evaluative methods and some measure of its epidemiologic effect. King has been concerned primarily with child care, and in Indonesia he has designed health care packages, for example, for treatment of the dehydrated child and the child with diarrhea. In terms of human rights, would his concept be useful in Canada? A key consideration is King's view that health care packages are both an approach to defining rights in health
590 CMA JOURNAL/APRIL 3, 1976/VOL. 114
care and a way of implementing them. Consider two examples: the case of a pregnant woman at term in a developing country and that of another woman in Canada. As a matter of human rights, would not access to an obstetrici.in capable of performing a cesarean section be considered basic for both women? Certainly few would disagree, but in Canada one must go further: as a matter of human rights a woman should have access also to a competent anesthetist who can, for example, perform endotracheal intubation skilfully and rapidly. Human rights in health for Canadians are in part determined by the standard of health care, in such a way that a pregnant woman should have available to her a number of health care packages, just one of which is safe anesthesia. For Canadians health care packaging is a concept that perhaps has administrative and political connotations, but it could be useful in evaluating the adequacy of health care, and its greatest use might well lie in stimulating us to analyse component problems in the entire health care delivery system, particularly primary care and the training of physicians. DAYm A.E. SHEPHARD References 1. BRYANT 3: Health and the Developing World, Ithaca, NY, Cornell University, 1969 2. KING M: Personal health care: the quest for a human right, in Human Rights in Health, Ciba Foundation Symposium 23 (new series), Amsterdam, Associated Scientific Publishers, 1974
