Bioethics Blogs

Fee-for-service: an ethical conflict

Andrew Mitchell suggests that innovative institutional changes are needed to sustain universal healthcare in Canada.


When Canadian provinces instituted universal healthcare, doctors were reluctant to become salaried employees, so a system of fee-for-service was developed. This payment model creates incentives for physicians to focus on quantity instead of quality of care and turns patients into bits of piecework. Indeed, most of us have experienced the whirlwind consultation with a doctor eager to get to the next patient.

Fees for specialist services are greater than those for family doctors. This encourages physicians-in-training to specialize and reduces the supply of family doctors. On average, doctors in Canada earn over $250,000 annually. Specialists often make twice this amount. Some specialists earn more than a million dollars a year. These kinds of salaries encourage individuals to enter medicine for reasons of high income and status, rather than a true desire to serve those who are sick.

Healthcare services are expensive and so they are rationed by provincial governments that restrict both the numbers of doctors and specialists, and the availability of operating rooms and diagnostic equipment. In this way, governments create an artificial, administered market for healthcare characterized by a scarcity of healthcare providers and high costs. This rationing often results in wait times for treatment, with some patients waiting for more than a year in pain and distress.

Physician associations have bargained with provincial governments and received benefits for doctors that usually would be considered employee benefits. In British Columbia, for example, the benefits include a disability plan and continuing education benefits.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.