no plague for the argument that didn’t happen

what if philanthropy funded readiness?

Earlier this year I sat in a room and listened to what the next decade of healthcare in Hamilton might look like. Diagnostics that catch disease earlier. Treatment matched precisely to the person receiving it. Research that will change what a diagnosis means for people who haven't yet had one.

It was extraordinary. And somewhere in the middle of it, a question arrived that I haven't been able to put down.

All of that innovation is aimed at how healthcare responds to illness. How much of the same energy goes into preparing people for the system they're eventually going to encounter?

Not preparing them medically. Preparing them for the decisions.

Because many families will eventually find themselves in a room being asked questions they never expected to answer. Would he want this? Would she have accepted that? And the honest answer, far more often than anyone would like, is that they don't know — not because the family didn't care, but because the conversation never happened out loud.

I've watched this from two directions. As a facilitator, sitting with people doing the preparation deliberately. And as a volunteer on a palliative care unit, sitting with families facing those questions for the first time, at one of the hardest possible moments.

So I met with someone who has spent more than twenty years raising money for healthcare to ask: could philanthropy fund readiness?

I expected the answer to be about whether the need was real. It wasn't — she agreed the gap exists. What I came away understanding was more useful, and more complicated.

The hierarchy nobody writes down

There's a hierarchy in how easy things are to fund, and it doesn't necessarily correspond to how much they matter.

Tangible things are easiest. A machine, a wing, a piece of equipment — a donor can see it, stand next to it, understand what their money became. Programmes are harder; the outcome is real but diffuse, and has to be explained rather than shown. People are hardest of all. Funding someone's time and expertise doesn't produce a visible object at the end of the gift.

Preparedness is a person, delivering a programme, producing an outcome that's largely invisible when it works.

That isn't cynicism about donors. Nobody is wrong for wanting to understand what their gift did. The difficulty is that readiness is defined partly by absence. A family who arrives prepared doesn't generate an obvious story about what was prevented. There's no photograph of the crisis that went differently because someone had already said what they wanted. No plaque for the argument that didn't happen.

The argument that might work

Unpreparedness has costs too — some borne by the system, some by families, some financial and some measured in time, conflict and the unpaid work of relatives navigating an already difficult situation.

There is evidence, though it's more mixed than advocates sometimes suggest. A systematic review of facilitated advance care planning programmes found reduced costs in six of the seven studies it examined, varying enormously by what was measured and over what period. The seventh found no difference.

And there's a longstanding counter-argument worth acknowledging. A 1994 analysis in the New England Journal of Medicine estimated that even under generous assumptions, reducing aggressive treatment at the end of life would save only a small fraction of total health spending. Its reasons still hold: it's genuinely difficult to know in advance who is dying, and planning doesn't necessarily lead people to choose less treatment. Some choose more.

That last point matters to me. Preparedness is not a cost-cutting exercise dressed up as a values one. Some people who plan properly will ask for everything medicine can offer. The purpose isn't to reduce treatment — it's to make sure what happens is what the person would have chosen.

But the cost question still deserves an answer, because it's the question a funder will ask. Healthcare and families already absorb some of the consequences of people being unprepared. What's understood far less clearly is what those consequences collectively cost.

If readiness is hard to fund because its benefit is hard to see, perhaps the answer isn't to argue harder that it matters. Perhaps the cost of its absence needs to be made visible.

Where the money might actually come from

Many significant gifts don't begin with someone persuaded by a strategy document. They begin with an experience, or with a family wanting to honour someone.

Which means the funding pathway for preparedness may never start with a foundation deciding to invest in upstream infrastructure. It may look smaller and much more human: one family who watched a difficult experience unfold, understood what might have made it different, and decided another family should be better prepared than they were.

That is a narrower door than the one I was looking for. But it is a real one, and it is open.

The parallel I keep thinking about

Fundraisers can spend years building relationships with people who intend to leave a charitable gift in their will. And sometimes that intention is never clearly communicated to the people who'll be involved in carrying it out. It exists — it was simply never made explicit, never written down, never said out loud.

Read that again with a healthcare decision in place of a charitable gift.

Someone may have a very clear sense of what they would and wouldn't want. They may have thought about it many times. They may assume the people closest to them know. But if it's never been said out loud, the people who eventually have to act are still left working it out.

Philanthropy and advance care planning are, in this one respect, in the same business. Both depend on someone being willing to say what they want while they still can. Both become much harder when they don't.

Where this leaves the question

I went in asking whether preparedness could be treated as healthcare infrastructure. I came away understanding why, from a philanthropic perspective, that's a difficult proposition.

I'm choosing to find that clarifying rather than discouraging, because the question that replaces it is sharper.

If readiness is hard to fund as infrastructure, hard to make tangible, and hardest of all when delivery depends on paying for someone's time — what would have to be true for it to become fundable?

Better evidence that prepared families cost the system less? A population specific enough to make the need concrete? A way of measuring not what preparedness creates, but what it prevents?

Or simply the right family, at the right moment, deciding that this is how they want someone remembered?

I don't know yet.

I'd genuinely like to hear from people who think they do.