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Individual
Responsibility, Justice and Access to Health Care
Lavinia Jane Norton
Submitted in accordance with the requirements for the degree of PhD
The University of Leeds
Department of Philosophy
September 2001
The candidate confirms that the work submitted is her own and that
been
has
been
has
to
the
made
reference
given
where
credit
appropriate
work of others.
Acknowledgments
I would like to thank my supervisor,Jennifer Jackson,for her ongoing support and
development
the
throughout
of this thesis.
encouragement
Individual
Responsibility, Justice and Access to Health Care
Abstract
The aim of this thesis is to examinewhether it is morally defensibleto use
lifestyle as one of the criteria for rationing health care. I arguethat it is not
justifiable to use former lifestyle to selectpatientsfor treatment.
Chapter one outlines the principles of the NHS and discussesthe reality of
in
health
in
rationing
care provision Britain. I maintain that there is aprima
facie legal and moral right to health care and explore whether this right
imposesa responsibility on individuals to maintain a healthy lifestyle.
Chaptertwo critically examinessomeof the criteria, which are usedto ration
health care. Governmentpolicy documents,suchas 'The New NHS.,Modern.
Dependable.' (Departmentof Health 1997: 13) suggestthat patientsshouldbe
treated 'according to needand needalone.' I arguethat the conceptof
indeed
is
for
the
the distribution of medical
medical need
one of
proper criteria
resources. However, it is not the only relevant criterion and should be
consideredalong with other factors suchas patient choice, clinical and cost
including
Other
lifestyle
effectiveness.
criteria
age and
may also be relevant,
but in so far as they affect the probableclinical outcomesof treatment.
Chapterthree clarifies someof the contemporaryapproachesto distributive
justice and explorestheir implications for the allocation of health carebetween
individuals. I suggestthat an eclectic approachshould be adoptedwhere
considerationis given both to promoting individual choicesabout lifestyles
and protecting the welfare of the community. None of thesetheories of justice
into
lifestyle
that
taking
suggest
accountwhen allocating scarceresources
be
must unjust.
Chapterfour investigateswhether individuals should be held responsiblefor
their lifestyle. I arguethat somehealth related behaviour is voluntary and
therefore people might be held responsiblefor the consequencesof their
behaviour. However, in many caseshealth related behaviour may not be
influenced
because
have
been
by
factors
beyond
it
the
may
unduly
voluntary,
if
it
is
it
be
justifiable
individual.
Even
the
may
or
control of
voluntary,
blame,
discuss
deserve
in
I
takers
and
whether risk
any
excusable somecases.
for
delay
treatment
that
of medical
as a punishment
maintain
withdrawal or
former lifestyle is always wrong.
Chapter five arguesthat it is essentialfor health care professionalsto inform
does
health.
liberty,
interfere
This
to
their
their
not
with
and
people of risks
based
I
their
to
them
make choices
upon
own values. also examine
allows
is
it
justifiable
to use more coercive strategies,such as persuasion,
whether
in
legal
to
prohibition
order
and
encouragepeopleto maintain a
manipulation
healthy lifestyle.
Chapter six arguesthat it is not possibleto implement a policy to ration health care
partly on the basis of lifestyle in a fair way. I proposean alternative policy, which
involves taxation on certain products associatedwith risk. Chapter sevenexaminesa
variety of casesof rationing basedon lifestyle. I concludethat rationing accordingto
former lifestyle is not morally defensible.
Table of contents
Chapter One
THE NATIONAL HEALTH SERVICE: PRINCIEPLESAND REALITY
1.1
1.2
1.3
1.4
1.5
1.6
The principles of the National Health Service
Rationing and priority setting
Examples of rationing in practice
Is rationing of health care inevitable?
The right to health care
Do individuals have a responsibility to maintain a healthy
lifestyle?
Chapter Two
RATIONING SCARCE RESOURCES IN HEALTH
EXAMINATION
OF THE POSSIBLE CRITERIA
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
3.1
3.2
3.3
3.4
3.5
3.6
27
CARE - AN
Criteria for rationing in health care
Medical need
Patient desire
Clinical and Cost Effectiveness
Age
Waiting lists and lotteries
Desert
Conclusions
Chapter Three
JUSTICE AND THE ALLOCATION
DISTRIBUTIVE
CARE RESOURCES
2
7
11
14
19
34
35
39
41
47
53
56
59
OF HEALTH
Theories of distributive justice
The Libertarian approach to justice
The Socialist approach to justice
Justice according to Rawls
The Communitarian approach to justice
Conclusions about distributive justice and
the allocation of health care resources
62
65
74
77
87
96
Chapter Four
INDIVIDUAL RESPONSEBILITY
4.1
4.2
4.3
4.4
4.5
4.6
Does determinism make nonsenseof accountability?
Individual responsibility
Voluntary and Involuntary behaviour
Responsibility for our former selves
Unhealthy behaviour - justification and excuses
Should we blame people for their unhealthy lifestyle?
102
105
107
113
116
120
Chapter Five
HEALTH PROMOTION
5.1
5.2
5.3
5.4
5.5
5.6
ACCEPTABLE
THE
-
LIMITS
The value of health
Health promotion and health education
Persuasionand Manipulation
Coercion
Legal Prohibition
Is paternalismjustified in health care?
132
136
141
148
154
160
Chapter Six
CAN A POLICY, WHICH TAKES ACCOUNT OF LIFESTYLE IN THE
DISTRILBUTION OF HEALTH CARE, BE ]IMPLEMENTED IN A JUST
WAY?
6.1
6.2
6.3
6.4
Problems inherent in any policy, which seeksto
distribute health care resources according to lifestyle
Should Rationing be Implicit or Explicit?
The Mechanisms of Rationing
Alternative Policy Options
164
173
179
182
Chapter Seven
CASE STUDIES
Should smokers have equal accessto health care alongside
7.1
non-smokers?
Should alcoholics and non-alcoholics compete equally for
7.2
liver transplantation?
Should sportsmen and women contribute to the costs of treating
7.3
their injuries?
If competent patients do not comply with prescribed treatment,
7.4
NHS?
future
forfeit
the
they
care, on
should
Should 'lifestyle drugs' be prescribed on the NHS?
7.5
203
207
Chapter Eight
CONCLUSIONS
Conclusions
8.1
212
References
219
186
193
199
Chapter One
THE NATIONAL
HEALTH
SERVICE: PRINCIPLES
AND REALITY
1.1
The principles of the National Health Service
1.2
Rationing and priority setting
1.3
Examples of rationing in practice
1.4
Is rationing of health care inevitable?
1.5
The right to health care
1.6
lifestyle?
healthy
have
individuals
to
Do
a responsibility maintaina
1
1.1
The Principles of the National Health Service
The National Health Servicein Britain offers medicalcare to the entire population
-a
(comprehensive'servicedesignedto restore, protect and improve the health of the
nation. According to The National Health ServiceBill (1946), all the services,or any
it,
be
in
to
part of should available every citizen England and Wales,regardlessof
ability to pay, age, sex, employmentor vocation, areaof residence,or insurance
implies
(RMSO
limitations
1946).
The
Bill
that
there
original
are no
qualification
on
is
forfeit
Certainly,
individuals
health
there
that
no suggestion
might
care,
availability.
if they adopt certain unhealthylifestyles, or indulge in high-risk activities.
Indeed, Aneurin Bevan, the founder of the NHS statedthat 'medicaltreatmentand
in
be
to
care should made available rich and poor alike accordancewith medicalneed
have
Subsequent
(Ham
23).
by
1981:
reaffirmed
governments
and no other criteria'
believes
Charter
there
The
Patients'
that
the
government
theseprinciples.
emphasizes
founded,
NHS
fundamental
the
be
the
and
was
principles on which
must no changeto
The
White
(DOH
4).
1992:
from
be
financed
taxation
it
that should
general
primarily
in
Dependable.
'also
Modern.
NHS.
that
New
(1997:
'7he
13),
patients
Paper
states
"
the NHS will be treated 'according to needand needalone.
form
(BMA
2001)
that
Association
of
some
states
Nevertheless,the British Medical
This
that
inevitable.
been,
has
public
while
is
suggests
report
rationing and always
increasing
is
there
NHS
awareness
for
an
the
strong,
the
remains
principles of
support
the
the
that
Indeed,
of
delivery.
concept
in
the
difficulties
concludes
review
the
of
its
treatments
that
have
and
NHS, as a comprehensiveservicemay
outlived usefulness,
limited
be
will
effective,
cost
judged
not
Or
to
effectiveness,,
clinical
of
which are
in
funding,
increase
is
if
from
Even
as
there
an
increasinglybe excluded
provision.
it
2000),
that
(Department
Health
of
Plan'
NHS
rationing
'Ae
in
appears
of
proposed
Chapter
in
be
discussed
2.2
will
The concept of need
2
health care is a necessity.
In this introductory chapter,I will considerhow the objectivesof the National Health
Servicehave beenimplementedin practice and review current health careprovision in
determine
if the NHS has achievedtheseobjectivesin reality. I will clarify
to
order
and contrast the terms.,'rationing' and 'priority setting", and discusssomeof the
describe
I
various mechanismsof rationing. will
somerecent examplesof rationing in
health care and discusswhether rationing is inevitablein the future. Finally in this
health
I
the
to
comment
on
notion of a right
care, and make some
chapter, will
idea
individuals
have
the
that
a responsibilityto maintaintheir
preliminary points about
health.
The Royal Commission on the National Health Service was appointed in 1976 to
financial
best
determine
the
the
to
use and managementof
review the entire service and
(1979:
9)
Their
the
objectives underpinning
presents
report
and manpower resources.
the NHS as follows-
'Encourage and assistindividuals to remainhealthy;
Provide equality of entitlementto health services;
Provide a broad range of servicesof a high standard;
Provide equality of accessto these services;
Provide a servicefree at the time of use;
Satisfythe reasonableexpectationsof its users,
'
local
to
needs.
Remain a national serviceresponsive
be
in
lack
Someof these objectivesare controversial,
precision,and may somecases
health
how
it
is
professionals
care
For
strenuously
clear
not
example,
unattainable.
does
the
What
healthy.
professional
individuals
to
responsibility
remain
should assist
health?
known
to
in
risk
have if the patient choosesto partake activities, which are a
health
they
be
that
individuals
the
is
care
that
given
will
Secondly,there no guarantee
3
if
seek, only 'reasonableexpectations'will be satisfied. What are reasonable
expectationsgiven that resourcesare finite?
Nevertheless,these objectivesconfirm the principlesthat there shouldbe equity in the
distribution and use of health care, and that the serviceshouldbe 'free at the time
of
for
patients. However, the individual who paysfor eye checks,dentalcare and
use'
prescription chargesmay questionwhether health care is really free at the time of need.
The National Health Serviceand Community Care Act (1990) introducedthe concept
of the 'internal market' for health - separatingthe buyers(in the form of District
Health Authorities and G.P. fund holders) and sellers(in the form of hospitals). This
decisions
funding,
about
separationmade
and the provision of services,more explicit
and amenableto public scrutiny and there was correspondinglya raisedawareness
importantly
lack
health
the
the
care.
about
provision, or perhapsmore
of provision, of
The 1990 Act did not changýe
the legal obligationsimposedby the National Health
ServiceAct 1977. The Secretaryof State still hasa duty to continuethe promotion of
he
health
'to
to
'comprehensive
meet all
necessary
considers
extent
as
service'
such
a
'all
54).
The
(Newdick
1993
of
reasonable
precisemeaning
reasonablerequirements'
A
State,
by
Secretary
determined
'
the
remainscontroversial.
of
requirements, as
NHS
have
the
treatment
on
sought
number of well-publicized cases,where patients
differing
illustrated
have
demands,
been
denied
the
have
and
their
conflict
potential
and
2
health
be
careneed.
perceptionsabout what should classifiedas a
2 Weale S. 'Age blow to childless seeldng IVF, ' The Guardian October 18,1994. This article
because
NHS
denied
in
Scale
the
Julie
treatment
she was
on
describesthe caseof
vitro
who was
in
in
'Rationing
the
S.
Redmayne
Klein
R.
Also
36.
caseof
practice:
deemed to be too old at
see
I.
S.
V.
A.
Watt
Entwistle
Also
Medical
Journal
1993,306,1521-4.
British
'
see
fertilisation.
vitro
Journal
1996,312,
'
Medical
British
Child
B
'Media
J.
L.
the
Pehl
R.
case.
coverageof
Bradbury
1587-1591.
4
The concept of rationing was not apparentin the original White Paperof 1944,rather
the reverse: 'the proposed servicemust be comprehensivein two senses first that it is
availableto all people and second,that it covers all necessaryforms of health care'
(CMD6502 1944: 9). Nevertheless,the Royal Commission(1979) recognizesthe
impossibility of meeting 'all' demandsfor health care and hasaccordinglymodified its
stated objectivesto provide a 'broad range of services.' Health promotion, disease
prevention, cure, care and after care would be included. However, the Report
financial
finite
is
NHS
that
the
to
the
there
acknowledges
and
a
resourcesavailable
are
for
is
health
'It
to
the
misleadingto
need set priorities
allocation of
care resources.
have
be
is
It
Hard
NHS
to
that
the
choices
made.
a
pretend
can meet all expectations.
it
in
health
duty
to
to
the
the
those
clear
care
make
provision
of
prime
of
concerned
(CMND
7615
1979:
11).
rest of us what we can reasonablyexpect'
While the Royal Commissionof 1979 acknowledgesthe needto set priorities in health
be
the
to
to
there
notion of rationing.
accept
a
reluctance
appears
care provision,
Politicians tend to avoid discussionsabout the reality of rationing and prefer to talk
A.
1997).
Milburn
338;
(Bottomly
1994:
in
health
care
priorities
9
settin
. bout
t-,
1:
1
Regardless of the adopted terminology, the difficulty of making choices about who
is
'Unfortunately
there
is
health
in
no
be
treated
recognized:
well
care
should
health
to
limited
the
available
resources
universally acceptable method of apportioning
Commission
(Royal
the
on
different
between
NHS
the
possible users and services'
National Health Service CAIND 7615 1979: 52).
in
health
carewould
The explicit acknowledgmentof priority setting or rationing
However,
NHS.
the
principles
in
the
the
fundamental
of
principles
change
representa
the
treatments
have
on
to
the
specific
do
any
that
right
NHS
patients
not suggest
of the
decide
doctors
which
it
can
that
and
Rather
managers
politicians,
NHS.
appears
the
is
the
available
the
of
to
(if
constraints
patient,
within
offered
treatment any)
5
in
form
While
is
the
there
resources.
any
rationing
within
recent
of
recognition
no
deny
documents,
that rationing exists,the
government policy
and somepoliticians
health
both
the
reality of practice and
careprofessionalsand their
experienceof
be
different.
patients may very
6
1.2
Rationing and Priority Setting
According to Klein, Day and Redmayne(1996: 7), 'rationing' is
a word, which
conveysa senseof proportionality - dividing scarceresourcesin a fair way so that
everyonereceiveswhat is deemedto be their share. This notion of rationing was
in
evident the SecondWorld War when limited supplieswere rationedin Britain to
promote the equitabledistribution of food in order to meet everyone'sbasicnutritional
needs. Rationing can take place in any situation where there is demandand a
correspondingscarcity of resourcesso that decisionsabout distribution haveto be
made. Health care, higher education,housingand welfare servicesare all subjectto
current rationing in the United Kingdom.
Rationing in the health serviceis saidto involve 'the denialor dilution of something
that is potentially beneficialto the patient: he or sheis getting lessin the way of
treatment than might be thought desirablein a world with unlimited resources.' (Klein,
Day and Redmayne1995: 770). Rationing takes placein circumstanceswhere
provision is constrainedby considerationsof cost and /or limited facilities suchas
diagnostic
specialiststaff,
equipment,operatingtheatresor organsfor transplantation.
Priority setting, a phraseoften adoptedby politicians (Bottomley 1994: 338), implies
that servicesare availablefor everyone,but somewill be treatedbefore others. The
idea of prioritization is not new and both in wartime conditions,and in major
be
diverted
form
Resources
is
triage
may
of priority setting.
operatedas a
accidents,
towards those most likely to survive, those in immediatedanger,and thosewho may
be able to assistothers. Virginia Bottornley (1994: 338) statesthat the government
has a legitimate role to play in setting priorities for the health service,but deniesthat
health
freely
is
by
'As
is
available
everyone covered a universaland
rationing a reality:
11
is
than
the
sharingout resources.
problem one of setting priorities rather
service
7
However, the distinction between
rationing and priority settingmay be blurred sincea
particular treatment may be given such a low priority, that in reality it
meansthat
nobody will receivethe treatment, and it is in effect withdrawn. Alternately,
patients
be
may placed on a waiting list, which is so long that in practicethey will
neverreach
the top and in effect treatment is deniedat the time of need.
Klein et al (1996:7) suggestthat the term 'rationing' shouldbe
reservedto describe'the
processby which resourcesare allocatedto individuals at the point of serviceor
programmedelivery.' This notion is distinguishedfrom 'priority setting' which is used
to describethe processof settingthe budgetsfor specific servicesat governmentor
departmentallevel. This contrast is sometimesmadeby referenceto
n-&roallocation
and macroallocationof resources(Daniels 1985:1), where decisionsat the macrolevel
determinewhat kinds of health care serviceswill be provided, who will deliverthem
how
they will be financed. It is misleadingto draw a sharpdividing line between
and
levels
decision
macro and micro
of
making, becauseprofessionalsmaking choices
about which patients shouldbe treated, (microallocation),are obviouslyinfluencedby
the overall institutional policies and macroallocationof resources.
In this thesis,,I will adopt the term 'rationing' becauseI shallbe concernedmainly with
decisionsabout which individual shouldbe treated, when it is not possibleto treat
because
first
limited
treatment
the
everyone,with
of
choice,
of
resources. In essence,I
decisions
health
those
the
care resourcesand
am concernedwith
micro allocation of
is
I
by
health
made
care professionalsabout which patient given scarceresources. will
health
justifiable
be
it
to
to
care
a
or
allocate,
withdraw,
would
explore whether
lifestyle.
basis
his
her
the
previous
of
or
particular patient partly on
There are various forms of rationing evident in practice. Health careprovision canbe
in
lists,
by
denial,
in
delay,
by
the
the
case
of
as
caseof refusing
waiting
or
as
rationed
8
treatment - such as removal of tattoos, or surgeryfor varicose
veins. Individuals can
be refused treatment, becauseof their
lifestyle,
age or
either explicitly, or implicitly
-
when doctors refer patientsto other agencies,suchas social services. Alternately,
people can be deterredby delaysin seeingthe doctor of their choice,by waiting times
at clinics.,or by difficult journeys.
As alreadynoted, (page 4 footnote 2), rationing may occur by excludingparticular
treatments,or refusing to treat certain medicalconditions. This form of rationing has
beentried and tested in the American State of Oregon,where medicalservices
availableon Medicaid are rationed accordingto a formula, which takes accountof the
public perceptionsof the relative worth of eachtreatment(Dixon Gilbert Welch 1991:
891). If a treatment is below the so-called'funding line' it is simplynot offered on
Medicaid. Such a policy does not discriminatebetweenidentified individualsand does
judgements
not explicitly make
about the worth, lifestyle or desertof any particular
Oregan
do
However
the
person.
preferences seemto reflect popular antipathy
someof
for the undeservingill suchas alcoholicsand the promiscuous.
While these examplesof rationing restrict accessto services,rationing can alsotake
is
For
by
the
'dilution'
number
example,
offered.
of
service
poor
quality
a
where
place
is
investigations
is
is
the
numberof
of qualified staff reduced,the environment poor,
3
limited, and the quality of care doesnot reachan acceptablestandardfor either staff
Cinderella
in
been
have
the
Such
so-called
evident
sometimes
conditions
or patients.
illness
disabilities,
learning
long-term
for
and
those
mental
the
with
and
elderly
services
be
dilution
the
(1998)
Klein
that
most
disability.
may
of
services
suggests
physical
forms
be
Patients
to
of
form
accept
alternative
on
prevailed
can
rationing.
of
prevalent
3 Hanratty et al (2000) found that women admitted to hospital for acute myocardial infarction would
be
likely
less
to
have
heart
investigations
than men who
attacks and were
be recommended for fewer
heart
have
is
that
The
drugs.
that
the
who
women
reason
authors
suggest
the
effective
most
given
difference
Nevertheless,
the
for
treated
be
than
similar
conditions.
men
are
to
who
tend
older
attacks
diagnostic
treatment.
tests
justify
and
does
of
appropriate
withholding
in age
not
9
treatment rather than their preferred option, and doctors can prescribesecondchoice
drugs in order to reduce expenditure,and use the best only if they fail (Newdick 1995:
278). For example,people with schizophreniacould be deniedmodem drugs as a first
line treatment, unlessthey have alreadysufferedunacceptablesideeffectsor failed to
respondto traditional therapies (Donnelly 1,999-.8).
Other distinctions betweenmethodsof rationing shouldbe noted. Thereis a difference
between allowing only certain peopleto gain accessto medicalcareas comparedto
the scenariowhere everyoneis offered a limited amountof medicalcare. This may be
illustrated by analogyto alternativecar parking policies. The policy may allow certain
it
for
firm,
the
to
park, or may allow anyoneto
people,
example,only employeesof
health
be
in
distinction
for
limited
but
This
time.
only
may not always relevant
park,
a
divisible
in
If
does
because
treatment
units;
not come easily
medical
care provision
is
it
is
to
the
to
not
entitled
patient
suggest
no
sense
makes
cardiac surgery proposed,
blood transfusionsor an intensivecarebed for more than two days. But for women
but
is
it
infertility
to
treatment,
possible allow everyoneaccess only
who are receiving
for two attempts at IVF or GIFT.
10
1.3
Examples of rationing in practice
While we may be reluctant to implementany rationing in health
it
care, appearsto be a
in
reality the NHS. The British Medical Association(1993: 299) statesunequivocally:
'In practice rationing of health care has alwaysexisted
within the NHS, although
rationing decisionshave frequently not beentaken openly.' All healthcare
professionalsare involved in decisionsabout resourceallocation,,because'resources'
just
are not
a matter of limited budgets,but include the allocationof time, skills and
facilities,
other medical
such as specialistequipmentand beds.
For example,the individual practitioner must decideon competingdemandsfor health
education,psychologicalsupport, physicalcare and giving information regardingthe
in
Most
treatment
possible
options.
peopleworking the NHS will recognize,(and
bitterly)
identify
is
limited,
that
their
time
that
they
complain
must
priorities and
so
interventions;
between
the
therapeutic
roles, skills and possible
make choices
various
between
different
further,
patients.
and
If a nurse decidesto spendhalf an hour talking with bereavedrelativesthis may result
in delaying or sacrificing a teaching sessionabout a healthydiet for anotherpatient.
know
bed
to
intensive
theatre
Doctors who allocate an
one patient
or operating
care
denied
be
delayed
for
or
altogether.
anotherwill
that this may meanthat the treatment
Hence.,all health care professionalstake decisionsconcerningresourceallocationand
rationing.
in
that
the
suggest
media,
which
There are severalanecdotalaccountsand reports
be
desire
NHS,
they
might
and
which
the
treatment
which
on
patients are not offered
March
1995,
In
there
limited
because
was
for
resources.
them,
beneficial
of
11
widespreadmedia coverageconcerningChild B (JaymeeBowen)' who was denied
further treatment for leukaemiaby Huntingdon Health Authority. Patients
who are in
severepain and have to wait for severalmonths on the waiting lists for hip replacement
operations, and people with multiple sclerosiswho are not prescribedinterferonbeta
(Dyer 1997), may know that rationing of health care provision is
a reality.
There is also anecdotalevidencethat rationing accordingto ageis practicedin the
NHS. Whitfield (1999: 10) suggeststhat in-vitro fertilization is fundedaccordingto
age, with one health authority restricting funding to those aged35, no older andno
Old
younger.
ageis also cited as a criterion for rationing. Elderly patientsmay be
admitted to generalmedicalwards rather than coronary careunits following cardiac
problems. This may be a form of rationing by dilution, where an inferior serviceis
offered to somepatients. There are also suggestionsthat surgerymay be delayedor
for
denied
(Dinsale
1996).
even
elderly patients
Age Concern state that one in twenty people over the age of 65 have been refused
4;7
treatment by the NHS, and in a survey conducted for the charity, many people
following
different
50th
had
their
that
their
treatment
they
that
was
noticed
suggested
birthday (Beecham1999: 1095). Bowling (1999: 1353)presentsevidencethat there is
life
fewer
in
enhancing
widespreadageism cardiology with older patientsreceiving
investigationsand interventionsthat the younger population. Young Robinsonand
disorganized
is
for
Dickinson (1998) presentevidencethat rehabilitation older people
(1997.
Grimley
Evans
best
despite
inadequate
practice.
clear guidelinesabout
and
be
NHS
in
to
discriminated
the
and continue
115) statesthat older people are
against
Le
New
because
they
and
old.
are
treatment
inadequate
simply
rate
or secondoffered
denied
73-year
describe
physiotherapy
old manwas
Grand (1996) also
a casewhere a
becausehe was over 65.
British
Child
B
Media
R.
Pehl
L.
J.
the
S.
Bradbury
I.
Watt
case
4 SeeEntwistleVA
coverageof
and
Medical Journal 1996.312: 1587-91
12
In addition, despitethe claim that the NHS
offers equality of geographicalaccess,it is
documented
well
that there are wide variations in the availability of servicesin the
different geographicalregions and trusts,
is
which unrelatedto the differing needsof
the population. Somehealth authoritieshave identified particular
services,which they
will not purchase,including GIFT and IVF for infertility (RedmayneKlein 1993
1521). Treatmentssuch astattoo removal, reversal
of sterilization/ vasectomy,
cosmetic surgery, and genderreassignmentsurgeryhavebeenremovedfrom NHS
provision in a few areas(BMA 1995: 8). Theseare clearly examplesof denying
particular serviceson the NHS, eventhough patientsmay demandsuchtreatments,and
indeed might benefit from them.
The governmentrecognizesthat there are major variationsin health servicesbetween
different areas:for examplethe level of cervical screening,and mortality from
carcinomaof the colon show substantialdifferencesbetweenhealthauthorities
(Department of Health 1997). In addition, Bellis, McVeigh and Thomson(1999) have
dying
largely
from
depends
lives,
AIDS
that
the
the
shown
chancesof
on where
patient
follows
funding
It
treated
that the availabilityof
per person
as
varies significantly.
treatmentsvaries and this has an impact on the morbidity andultimately the mortality
of patients.
Other health authorities avoid explicit rationing by denial or exclusion,preferringto
form
less
of rationing where certain servicesand
controversial
adopt a vague and
limited
Within
in
low
the
be
priority resourceallocation.
given a
procedureswould
budget, clinicians can decidewhom to treat, and how and when to treat, accordingto
by
be
be
Such
criteria may not madeexplicit, and may concealed
their own criteria.
(Hope,
for
indicated'
is
'not
the
patient
clinically
the suggestionthat treatment
discussion
Public
379).
1993:
Crisp
Sprigings and
about the problemsassociatedwith
be
therefore
funds
avoided.
limited
and resourcescan
13
1.4
Is rationing of health care inevitable?
Prior to any discussionabout the just
for
distinguishingbetweenindividuals,in
criteria
the allocation of scarcehealth care resources,we should ask if
rationing in the NHS is
inevitable? Will resourcesfor health care
provision alwaysbe limited, and win
demandcontinue to rise? Perhapsit would be possibleto increasethe budgetfor
health care, or managea more efficient service,so that
peoplecould be treated
according to their needsand demands?
I will suggestthat rationing in the NHS is inevitable, Even if an increasedproportion
of the government'sbudget is allocatedto the NHS, it would still be necessaryto
refuse certain treatmentsto somepatients,treatmentsfrom which they might benefit.
This doesnot meanthat rationing is desirable,but I will arguethat the demandfor
health care will continue to rise, despitea more efficient service,and a more effective
health educationand promotion programme,which may improve the generalhealthof
the nation. Secondly,I will arguethat resourcesavailablefor the NHS will alwaysbe
however
financial
the
the
restricted,
economyof the
efficient
serviceand whatever
coUntrY.
Rationing hasbeen evident sincethe formation of the NHS, andwas clearly
Service
(1979:
5
1)
National
Health
Commission
by
Royal
the
the
on
acknowledged
'The demandfor health care is alwayslikely to outstrip supply and the capacityof
health servicesto absorbresourcesis almostunlimited. Choiceshavethereforeto be
Royal
be
'
The
have
funds
to
set.
and priorities
made about the use of available
College of Physicians(1995: iv) are in agreementthat not all public expectationscan
be met within the NHS so that choiceswill haveto be made.
NHS
'with
to
that
the
182)
(1989:
continue
will
Klein
absolute
confidence'
predicts
14
generatemore demandson the political economy. He writes: 'Even if the lin-fitations
of medical technology in curing diseaseand disability are now becomingapparent,
there are no suchlimitations on the scopeof health servicesfor
providing carefor
those who cannot be cured. Even if policies of preventionand social
engineeringwere
to be successfullyintroduced, their very successin extendinglife expectancy
would
demands
for alleviatingthe chronic degenerativediseasesof old age. In
createnew
short, no policy can ensurethat peoplewill drop deadpainlesslyat the ageof 80, not
having troubled the health servicespreviously.'
This presentsa peculiar irony in that the very successof medicineto prolong life
in
expectancyresults a greater demandfor servicesand associatedincreasedcoststo
meet those demands. Simply expressed- when peoplelive longer they requiremore
health care becausethere is a higher incidenceof chronic diseasein old age. Chronic
illness is not susceptibleto cure, but demandson going care and support,with
financial
associated
costs. While the maximumhumanlife spanhasnot changed
in
live
increase
do
is
100
there
significantly - people not
a notable
much after
yearsthe averagelife expectancyof both men and women in the developedcountries. The
demographicchangeresulting from an ageingpopulation hasundoubtedlybeena
Population
for
health
demand
in
increased
this
the
century.
care
major cause
(Khaw
1999)
increasing
future
for
that
the
elderly population
an
suggest
projections
issue.
this
will compound
The rise in demandfor health care also resultsfrom a greaterpublic awarenessof
development
founded
the
NHS
to
The
of
treatments.
prior
was
medical
possible
dialysis
life
or
highly sophisticatedtechnical care suchas
support machines,renal
for
treatment
manyconditions.
options
transplantation and there are now a variety of
for
both
drugs,
immunosupressive
A.
T.
Z.
drugs,
and other
suchas
New and expensive
beneficial
been
have
are
treatment,
results
marketed
and
and
preventative medicine
15
widely proclaimed by the media. Public expectationhaschangedaccordingly;Mason
and McCall Smith (1994: 248) claim that the choice of treatmentis increasingly
influencedby patient's demandswith a proportionate
erosionof the doctor's clinical
discretion.
In addition, health care needsare not static, but evolve as
new technologyand
envirom-nentalfactors develop. The expectationsof the public, andthe demandfor
forms
new
of treatment and drugs are increasing. Diseaseitself changesasillustrated
by the developmentof AIDS and varient Creutzfeldt-Jakobdisease.Dubos (1968. 75)
states:'It is a dangerouserror to believethat diseasesand sufferingcanbe wiped out
by
altogether raising still further standardsof living, increasingour masteryof the
environmentand developingnew therapeuticprocedures.The lesspleasantreality is
that, sincethe world is ever changing,eachperiod and eachtype of civilization will
continue to have its burden of diseasecreatedby the unavoidablefailure of biological
and social adaptationto counter new environmentalthreats.'
Increasingdemandsand costs in the NHS are reflectedin the availableinternational
data. Brody (1992: 10-11) provides evidencefrom the OECD (Organisationfor
Economic Co-operation and Development)to show there hasbeensubstantialgrowth
in health care expenditurethroughout all of the developedcountriesduring the last
'
has
independently
has
happened
five
This
the
twentycountry
of whether
rise
years.
had a privately owned health care system,or primarily governmentowned system,
including
the
In
NHSBritish
the
countries,
number
of
a
response,
such as
discussed
have
Sweden
Israel
New
Zealand,
Scandinavia,
Netherlands,
explicit
and
5 Doyal (1995: 281-282) questions whether the demand for healthcare resourcesreally will continue to
futile
if
the
to
taken
of
provision
that
out
minimise waste and rule
increase. He suggests
steps are
funding
for
he
increase.
In
that
demand
extra
suggests
addition,
may not
treatment, then predicted
health care could be found by increasing the allocated percentageof the gross national product and
in
he
be
Nevertheless,
the
that
world
real
states
met.
of
needs
could
proportion
greater
consequently a
He
funding
between
to
be
need.
and resources meet medical
a significant gap
there is likely to
inevitable.
is
health
in
therefore
care
concludes that rationing
16
policy options for rationing of health care resources.6
In summary,it appearsthat the demandfor health care
will continueto rise, and yet
resourcesare finite and there will alwaysbe a limit to the provision of health care,both
financially, and in respectto availableskills, qualified
staff and resourcessuchas
for
transplantation.It is important to recognizethat the NHS hasto compete
organs
with other public sector servicesfor its shareof availablefunds. Thosewho claim that
the budget for health shouldbe increasedaccordingto demand,becausehealthis a
'basic need,' must accept sucha decisionwill inevitably lead to a reducedbudgetfor
such servicesas education,housing and social services. Theseservicesalsomeetthe,
'basic needs' of the population, and undoubtedlyaffect the healthof individuals.
It is stating the obvious to saythat good health and the absenceof diseasedo not
dependsolely on the health service. Rather it appearsthat good healthwill depend
housing,
factors
relevanteducation
such as environmentalconditions,
upon a variety of
lifestyle.
healthy
diet
Hospitals
the
andthe
and
and
promotion and availability of a
longer
is
individual
last
health
the
no
resort when
acute
servicesare only required as a
healthy. Indeed the majority of determinantsof health suchas lifestyle, genetic
by
interventions
influenced
makeup, social and envirom-nentalconditions are not
NHS.
from
the
the
acute sector of
currently available
health
influences
the
is
of the nation
It relevant to note that perhapsthe greatest
on
Public
1848
The
For
NHS.
from
the
have arisen
example:
policy changesoutside
Health Act introduced the provision of adequatewater suppliesand seweragesystems,
diseases,
infectious
dramatic
and
in
cholera
such
as
of
reduction
which resulted a
intervene
to
typhoid, at a time when the medicalprofessionwere virtually powerless
(1994:
71)
Calman
the
Officer,
that
Kenneth
Chief
Medical
The
states
7).
(Ham 1992:
in
describes
Holm
(1998)
the
discuss
these options.
prmess of rationing
6 Coulter and Ham (2000)
in
Israel.
discuss
(1998)
Israeli
Galai
the
Shalev,
policy
and
Scandinavia. Chinitz,
17
funding of utilities such as transport, police, educationand the environmentmay have a
more important impact on health than spendingon health care. The financial allocation
of resourcesto health must, therefore, be consideredin the light of the competing
between
claims
various sectorsof public expenditure.
In conclusion,the resourcesavailablefor the NHS will alwaysbe restricted sincethere
be
balance
between
including
the
the
must a
various competingneedsof
community,
by
housing,
The
transport
and sport.
obligation the governmentto provide
education,
health care must therefore, be seenwithin the context of other basicrights, obligations
determine
decision
It
(Brody
14).
to
1992:
remains an essentially political
and values
but
health
be
there
to
the
care,
will
allocated
should
national resources
what share of
health
for
demands
be
between
the
the
availableresources,and
care
and
always a gap
hencethere will alwaysbe rationing.
18
1.5
The Right to health care
Legal rights arejustified claimsbasedupon the principlesand rules establishedin the
legal
law
If
the
prevailing
system.
changesthen the associatedlegal rights will change
accordingly. The Human Rights Act cameinto full effect on October 2,2000
throughout the United Kingdom, and statesthat all courts must give effect to the
provisions of the EuropeanConvention of Human Rights. This meansthat for the first
time, British people will havethe right to enforcea rangeof civil and political rights in
their own courts, rather than having to presenttheir casesto the EuropeanCourt of
Human Rights in Strasbourg. Among the rights includedare the right to life, respect
for private and family life, and the right to freedomfrom inhumanand degrading
treatment. Dyer (1998: 1339) statesthat 'implementationof the act is certainto bring
issuesof NHS resourcesand healthcarerationing to the fore.' For example,it is
invoke
basis
denied
to
the
treatment
that
right
may
cost
of
on
patientswho are
possible
life arguments.
in
legal
by
has
been
this
health
the
'right
However the
system
to
recognized
not
care'
form
NHS
the
health
take
legal
the
of
to
usually
within
care
rights
country, since
Health
National
The
individual
duties,
than
entitlements.
rather
statutory
general
duty
State's
Secretary
to
is
'It
(1)
the
1
Section
that:
of
1977,
ServicesAct,
states
health
Wales
in
England
service
comprehensive
of
a
the
and
promotion
continue
designedto secureimprovement (a) in the physical and mental health of the people of those countriesand
the
illness,
to
diagnosis
secure
or
treatment
provide
and
of
(b) in the prevention,
and
AcC
in
this
with
accordance
of
services
effective provision
duty
has
Minister
to
implies
further
services
the
(1),
that
provide
3
a
Section
The Act,
The
to
he
requirements.
all
meet
reasonable
necessary
considers
to such an extent, as
19
Act does not, therefore, establishan absolute
right to health carefor individuals
according to their perceivedrequirements. This hasbeenconfirmedin the courts
judges
have upheld the decisionof certaintrusts / health
where
authoritiesnot to treat
7
patients according to their demandsor their parents' demands.
People in England and Wales do have a legal right to the provision of 'free' health
care
(more accuratelydescribedas taxation financed),but the precisenatureand level
of
'
is
indeterminate.
this entitlement
This right implies a duty on someagencyof the
governmentto act, namelythe NHS, rather than a duty on any particularindividual. In
9
legal
health
is
other words, the
right to
care a claim right againstthe stateratherthan
fellow
a right against
citizens.An unconditionalright to healthcare doesnot exist
becausehealth care professionalsdecidewhich treatmentsare effectiveandwhich will
legislation
in
According
Englandand
the
to
meet
clinical needsof patients.
current
Wales, there is no individual right to a specificprocedure,or to its delivery at a stated
time and / or place (Dyer 1987: 1554).
Ihe Patient's Charter' (Departmentof Health 1991) setsout the rights and standards
include
'to
These
from
NHS.
in
the
Britain
the
receive
that everyone
fight
can expect
health care on the basisof clinical need,regardlessof the ability to pay; to be
'
time,
GP;
a
amongst
to
any
at
care
medical
emergency
receive
and
registeredwith a
(1997:
60)
that
Montgomery
states
three
new rights.
total of sevenexisting rights and
be
but
legally
that
they
may enforceable
enforceablerights,
this Charter does not create
(1991.
Charter'
Patient's
'The
in
law.
However,
where they are alreadyrecognised
(1996)
in
Entwistle
Bowen
Jaymee
et
al
For example seethe caseof
Services
Health
National
following
the
and
legal
rights of patients
Newdick (1993) discussesthe
Community Care Act 1990.
imposes
liberties:
an
a claim right
9 Lockwood (1981: 150) adopts the terminology of claim rights and
liberty
'service'.
In
in
rights
behave
contrast,
a
and
provide
ways
to
certain
obligation on others
if
in
they
refi-ain
freedom
should
to
others
have
and
choose
the
certain
ways
act
individuals
imply that
individuals
liberty
is
freedom
can
to
right:
The
speech
a
of
right
supposed
from interference.
is
do
(There
on
others
them
to
no
obligation
so.
allow
should
others
their
and
views
express
normally
to listen. )
20
19) requires all health authorities to publish information about their
performancein
relation to theserights and standards,and establishesa procedurefor complaints,if
individuals feel that they are being deniedany of their Charterrights.
The notion of somekind of legal right to health careis a relatively recent concept,
has
become
which
only
a practical reality in the United Kingdom with the creationof
the NHS. This servicewas establishedat a time in the history of medicinewhen great
had
been
achievements
recognised:antibiotics and infection control had madea
difference
both
to
the quality of life andthe expectedquantity of life. There
significant
highly
the
acute and
specialisedcarewith the associatedsoaring
was no anticipation of
have
been
developed.
Hence
NHS
the
was createdat a time
costs,which
subsequently
it
feasible
be
beneficial
to
outcomescould achievedat reasonablecost and was
when
think of a legal right to health care, which could be met at an affordablecost to society
as a whole.
With the ongoing progressin medicaltechnology and pharmacologyandthe current
become
has
health
legal
to
in
developments genetics,the concept of a
care
right
health
knowledge
to
light
the
today,
increasinglyproblematic. In the
right
of medical
determine
becomes
to
It
then
be
necessary
to
standard.
a
certain
restricted
care must
to
that
health
continues
question
is
provision
care
of
standard
acceptable
-a
what an
thinkers.
philosophical
challengepolitical and
depend
honoured
be
health
will
care can
In practice, the extent that a legal right to
upon
I
the
the
community.
of
wealth
economic
and
priorities
the prevailing political
be
it
to
in
NHS,
that
in
inevitable
possible
the
not
will
and
have arguedthat rationing
designated
If
desires
the
or
government
for
everyone.
of
the
needsand
provide
the
NHS)
to
Health
all
the
are unable provide
and
institutions (the Department of
21
health care that individuals need,becauseof limited resources,we cannot
saythat they
ought to do so.
The extent of the legal right to health care is further confusedby the ambiguityof the
term 'health'. Health is an exceedinglybroad concept,which is notoriously difficult to
define."' Health care may be primarily concernedwith the adequatefunctioning of the
humanbody: preventing disease,diagnosingillnessand providing treatmentif needed.
(This might be labelled asthe bio-medicalmodel.) However, this approachcanbe
idealistic
health
is
in
conceptof
contrastedwith a more expansiveand
which reflect6d
the World Health Organisationdefinition of health: 'a stateof completephysical,
disease
infirmity'
the
or
absenceof
mental, and social well-being, and not merely
(WHO 1946).11
While the treatment of cardiac angina,broken bonesor infectious diseasesis obviously
it
is
less
to
health
as
obvious
model,
medical
a
care needswithin
classifiedas meeting
indeed
infertility
for
treatment
or
surgery,
cosmetic
medicine,
preventative
whether
impotence, should be treated as health care needsby the NHS. Considerthe example
it
is
is
diseased
tissue
the
breast
to
uncontroversial,
remove
surgery
cancer;
while
of
NHS.
be
the
if
breast
determine
on
difficult
available
should
to
reconstruction
more
disease,
the
treatment
or restore
the
of
This latter surgerywill not contribute to
her
being
the
woman and
of
function, but may contribute to the psychologicalwell
idea
the
broader
in
defined
is
health
the
embracing
If
sense,
subsequentrehabilitation.
It
NHS.
be
the
would
breast
on
available
being,
should
then
reconstruction
of well
if
the
have
this
type
to
even
of
surgery
follow
access
that
should
a woman
also
discussion
Further
health.
defming
will
difficulty
of
10 Dines and Cribb (1993: 3-19) discussthe
5.1
in
take place chapter
100
2
Organisation
World
Health
Record
no,
Official
of
11International Health Conference 1946
29)
(1985:
Daniels
in
cited
22
reconstruction was not to remedy diseaseor surgerybut solelyto rectify personal
preferencesabout size- assumingthat the latter is causingpsychologicalillness
equivalentto that causedby disease.
While the legal rights of patientsto health care on the NHS are establishedin the
12
legislation,
British
current
some authors have arguedfor a moral right to healthcare.
This is basedon the idea that individuals have certain rights, which are intrinsic
entitlements,regardlessof what rights are establishedin the prevailinglegal system.
Doyal (1995: 273) has proposed that 'all humans should have equal rights of accessto
health care on the basis of equal needs.' He seeksto justify this claim by suggesting
that 'physical and mental health are necessaryconditions- they are 'needed"- for
(Doyal
1995: 275). If people are unable to
optimally successful social participation'
in
flourish
interactions,
be
they
to
participate normal social
andunableto
will
unable
fulfil their responsibilitiesto others in the community. However, Doyal doesnot
have
duty
to make people optimally successful
that
a
clarify why we should accept
we
from
Many
to
social participation at
people choose withdraw
at social participation.
birth
bereavement
lives
following
the
their
times
of
a
child.
or
of
particular
-
Doyal (1995) suggeststhat people shouldnot be deniedhealth care,becausephysical
for
becoming
health
good
citizen
a
and
remaining
conditions
necessary
are
and mental
'People
He
that
fulfilling
they
may possess. states
and
whatever personalpotential
(Doyal
flourish'
1995:
help
be
to
healthy
less
than they might cannot
others
who are
disabilities
idea
lead
that
to the unacceptable
peoplewith
275). This suggestionmight
illnesses
are not good citizens.
or chronic
12Doyal 1995, Daniels 1983, Daniels 1985
23
The notion of equal rights of accessto health care on the basis
13
of equalneeds, as
by
proposed Doyal, raisesa number of problems. How do you assessneeds
accurately? Does the mother with three dependentchildren needtreatmentmore than
the elderly man who lives alone? If we include the needsof the childrenfor a parent,
then we may meet 'more' needsby treating the mother. Can one really comparethe
needsof one patient.with another? The stoic personwho doesnot complainaboutthe
ongoing pain may be disadvantagedby any superficialassessment
of needs.
Different people will have different priorities: the stiff knee for the ballet dancermay
presentan immediatemedical need. However, a similar condition may not be a
for
lecturer
the
problem
more sedate
who choosesto avoid exerciseof any sort. Doyal
(1995: 276) admits that he is focusing on hospital care and hasdefined 'need' as 'the
for
intervention
disability.
"
to
requirement specific clinical
avoid sustainedand serious
Accordingly, resourcesshouldbe allocatedto life threateningconditionsandto those
including
irreversible
disability,
thosewho are suffering
who are at risk of seriousand
he
health
focus
Doyal
to
careand
on a restrictedmedicalmodel of
appears
acutepain.
health
issues
the
the
and generalwell
of whether we shouldpromote
avoids
wider
being of individuals. Elective surgery,cosmeticsurgery,and treatmentfor impotence
his
be
approach.
a priority, within
would not
He
health
idea
has
to
(1985)
care.
Norman Daniels
of a moral right
also examined the
from
is
derived
to
health
the
guarantee
to
obligation
social
that
the
care
right
argues
'fair equality of opportunity. ' He suggeststhat health care is a special social good,
The
kinds
from
differently
be
distributed
goods.
of
social
other
which should
distinction is made because health care meets certain important categories of need:
is
This
'
functioning.
'normal
a more
species
those that are necessaryto preserve
(1996:
189)
that
by
Daniels
Doyal,
writes
that
since
than
suggested
modest obligation
3.1
in
discussed
be
health
distribution
for
chapter
13Medicalneedasa criterion the
carewill
of
24
4e can characterisehealth care needsas things we needto maintain,restoreor
compensatefor the loss of normal speciesfunctioning.' Sinceseriousimpairmentsof
functioning
normal
can adverselyaffect the capabilitiesof people,they may also impair
the opportunity rangesfor individuals as comparedwith the normal rangefor society,14
Daniels usesthe term 'health care' broadly to include personalmedicalservicesand
health.
it
He
that
also preventativemedicineand public
suggests
embracesa diverse
institutions
health
imply
therefore
the
to
and
notion of a right
set of
care can
a number
in
is
being
both
different
to
the
things
regard
of
claimed
extent
what
andwith
of
(1985:
it
justification
Nevertheless,
Daniels
3
5)
that
to
type
the
of
needs.
regard
fairly
impairment
'we
the
that
normal opportunity rangeas a
of
shoulduse
concludes
level.
11
health-care
importance
the
the
macro
needsat
of
relative
crude measureof
Daniels suggeststhat medicalneed arisesfrom the loss of normal speciesfunctioning
both
health
it
follows
treat
to
that
physicaland psychological
care should seek
and
diseaseor injury, which adverselyaffectsnormal functioning. However, I would
health
cosmetic
as
such
provision
care
that
this
certain
exclude
might
approach
suggest
Even
health
breast
promotion.
therapies,
and
reconstruction
complementary
surgery,
interventions
functioning,
loss
for
these
beyond
treatment
of normal
though they go
the
the
to
of
NHS,
they
well-being
promote
the
seek
since
on
provided
are sometimes
to
important
is
seeks
health
within a service,which
individual. Indeed such
care vitally
individuals.
promote the generalwelfare of
Daniels (1996: 194) admits
health care and
maintaining
in
issues
distributive
that his account cannotresolve all
in
be
to
addition
he suggeststhat other considerationsmay relevant,
is
discussing
the
Anyway,
Daniels
a normal opportunity range.
lack
including
of
education
affect
opportunity,
can
14Daniels recognises that other social conditions
training
and/or relevantjob
25
macroallocation of resources,,while I am interestedin the distribution of healthcare
between individuals the microallocation of resources.
-
In conclusion,while the legal right to health care in Britain is reflectedin the statutory
duties of the Secretaryof Stateto provide a 'comprehensive'and 'free' health service
to all, the extent of this right remainscontroversial. Even if we agreethat there is a
legal right to health care, questionsremain about what is includedwithin this right.
The concept of health can be defined from a narrow medicalperspective,focusingon
diagnosisand treatment of diseaseor injury, or from a much broaderand more
inclusive approachembracingthe well-being of the individual. The claim of a legal
implied,
duties
itself
health
does
in
to
or
clarify what
and obligationsare
not
right
care
for
be
be
NHS,
the
care.
or who should eligible
what servicesshould availableon
Despite the difficulties in determiningthe extent of a moral right to healthcare,for the
health
is
to
I
that
there
care.
aprimafacie right
purposesof this thesis, will accept
There cannot be an absoluteright to health carebecausewe cannotmeet all claimsto
health care, and therefore we cannot saythat we ought to meet all claims. The central
by
health
forfeit
to
individuals
is
their
care
right
this
thesis
can
whether
question of
health
has
this
to
If
behaviour.
question
irresponsible
care
a right
nobody
their
impossible
is
it
to
treat
In
becomesmeaningless. the unfortunate situation where
delay
it
is
justifiable
to
medical
or
I
withdraw
to
everyone, wish explore whether
lifestyle,
taken
have
or
risks
from
an
unhealthy
those
adopted
treatment
people who
failed to comply with prescribedtreatment.
26
1.6
Do individuals have a responsibility to maintain a healthy lifestyle?
While the rights of patientshave been assertedin '7he Patients Charter' (Department
Health
1991) and have beenthe focus of debate,there hasbeenlittle discussion
of
about any correspondingresponsibilitiesof patients. The existenceof rights is often
balancedby certain responsibilities,which may imposeobligations" on the individual.
Indeedthe current Home Secretary,Jack Straw,16statesthat: 'The Government's
is
objective to promote a culture of rights and responsibilitiesthroughout our society.
This Act' (The Human Rights Act) 'will make peoplemore awareof the rights they
but
have
balances
theserights with responsibilitiesto others.'
already
also
I wish to
examinewhether the right to health careimposesa responsibilityon individualsto
healthy
lifestyle,
by
maintain a
either avoiding known risks or by taking positive steps
to promote their own health.
In Britain, contribution'to the NHS is by compulsorytaxation andthere is a pool of
financial
donated
both
organsand
resources,
resourcesand material resourcessuchas
beds. If somepeople take risks with their health and use more than their fair shareof
denied
On
illness,
be
for
the
treatment.
then
other
others
may
self-inflicted
resources,
hand, when people maintain a healthy lifestyle, and lower the incidenceof diseaseand
'
injury, then those who becomeill through no fault of their own, may be ableto benefit
despitelimited resources. The responsibilityto maintaina healthylifestyle may be
ill,
become
have
because
those
to
who
support
societywill
owed to society as a whole
Veatch (1981: 276-281) arguesthat where the needfor health careis self-generated,
bear
fair
it
the
health
is
to
to
behaviour,
ask
society
not
at risk,
through
which puts
health,
individuals,
their
NHS
take
In
risks
with
the
minimal
who
prudent
extra costs.
lifestyle
individuals
to
or
an
unhealthy
continue
pursue
those
who
will subsidise
151 will use the words obligation and duty interchangeably
16Cited in Home Office Press Office News Release Government to ""Bring Rights Home " on 2
October 2000 (12/07/00)
27
partake in dangeroussports and are subsequentlyill or injured. Gutmann(1995: 113)
statesthat 'The medical needsthat result from recklessbehaviour
be
may so expensive
to satisfy that society cannot then afford to meet the needs
of other peoplewho act
responsiblybut still suffer from misfortune.' In this way peoplewho adopt
unhealthy
lifestyles
or risky
may causeindirect harm to others.
It is also possiblefor individuals to causedirect harm to
othersif they do not look after
their health. When individuals suffer from an infectious diseaseand fail to take
appropriateprecautionsthere may be risks for others. Similarly, smokerscan cause
direct harm to others if there is no way to avoid the
effectsof passivesmoking. We
have a moral responsibility not to harm others,both in health
care and in life generally,
and it follows that individuals must take someresponsibilityfor their healthand
lifestyle, sinceself-neglectcan adverselyaffect others. Restrictions
on certaintypes of
behaviour are evident in our current legislation and arejustified if there is clear
evidencethat harm to others is likely to result. For example,speedrestrictionsfor
motorists will reducethe severity of injury in car accidentsand for pedestrians.
Individuals may also have a responsibilityto maintaina healthylifestyle becauseof
ongoing commitmentsto particular people. For example,parentsmay havea special
17
healthy
because
lifestyle
When
their
responsibilityto adopt a
of
young children.
individuals becomeill, or die prematurely,there is a tremendousloss for thosewho are
dependentupon them. When Alison Hargreaves(Beaumentand Douglas 1995: 10)
following
her
K2,
to
attempted climb
successfulclimb on Mount Everest,there were
in
following
her
death.
irresponsible
Was
the
to take
criticisms and questions
press
she
her
health
life,
had
If
two
and
she
children?
when
risk
with
young
such an obvious
" Sons and daughters are also expected to be responsiblefor the care of their aged parents
NHS
It
is
in
that
the
and
social
expenditure.
reducing
welfare
of
not
clear
a
climate
particularly
into
duty,
to
the
this
a
voluntary
agreement
accept
rather
enter
caring role
relatives
elderly
of
children
Dworkin
(1981:
26-3
Hence,
1)
is
that
fall
them.
to
suggests
responsibility
not always
upon
appears
voluntarily assumed.
28
such criticism is accepted, it implies that women have a particular responsibility to
healthy
lifestyle while their children are young and dependent. (At the
maintain a
time
Alison died on K2, two other male British Climbers
were swept to their death in an
in
avalanche, the same range of mountains. Both men had children and yet there were
no questions asked as to whether these fathers should have gone mountaineering.)
There are however inherent difficulties in acceptingthe claim that we have
a
responsibilityto maintain a healthy lifestyle. Firstly, there may be competing
individuals
health,
in
take
fulfil
obligations,
their
where
to
risks
with
order
other
,
responsibilities. For example,firemen or lifeguardsmay deliberatelyplacethemselves
in potential dangerin order to rescuethose in need. Secondly,the claim that
individuals have a responsibilityto maintain a healthylifestyle doesnot indicatethe
kind of the duty, whether it is only a negativeduty not to exposeoneselfto risks, or
it
is
duty
individual
improve
health?
haveto
Does
to
the
also a positive
whether
from
indulging
in
refrain
certain high- risk activities, or is there also a requirementfor
individuals to take active stepsin order to maintaintheir health,including taking
fibre
high
diet,
regular exercise,eating a
and putting on sunprotection cream?
Positive obligations or duties can be describedasthose in which the individual should
(Fishkin
For
1982:
8).
but
from
shouldperform certain acts
acting
not merely refrain
before
inoculation
duty
have
to
travelling
to
a
get
an
positive
a
example,you might
foreign destination,to minimisethe risks of potential infection, It is tempting to
"
harm
known
high
duty
to
is
to
risk activities, which are
avoid
suggestthat there a
health, such as smoking, parachutejumping and excessivesunbathing,but to denythat
health.
However,
the
duty
to
to
take
active steps maintain
there is a positive
18Except when there are conflicting obligations. For example, many people take justified risks in
injury
bc
the
pub owner may work within
at
physical
and
risk
of
may
jobs:
the
cleaner
their
window
just
themselves
to
ongoing
stress.
and
bar
subject
overwork
filled
may
others
and
smoke
29
distinction between positive
and negativeobligations is not alwaysobvious or clearly
defined, particularly in regard to
is
what an omission. Does the responsibilityto
maintain a healthy lifestyle involve a positive obligation to take regular
exerciseand eat
high
fibre
diet? Or is this a negativeobligation to
a
avoid a sedatelifestyle and a low
fibre diet?
The extent of such a responsibilityis not clear, and there
limits
to what can be
are
expectedof people. For example,the singlemother who haslittle help with child care
find
it difficult to partake in regular exercise. Shouldhigh-powered
may
executives
give up their stressfuljobs and move out of the polluted cities in order to improve their
health? Should people stop using the car and get on their bicyclesin
order to promote
their health? The responsibilityto maintain a healthylifestyle raisesthe questionasto
how much sacrificeis necessaryto fulfil the obligation.
Smiley (1992: 255) suggeststhat our judgementsabout the scopeof responsibilities
be
will
related to a variety of cultural assumptionsabout when, and how much,
individuals can be expectedto control their own behaviour. In particular, shefocuses
on our perception of social roles and communalboundaries. Responsibilityfor disease
injury
be
backdrop
and
can assessedagainsta
of expectationsabout who can and
should act (or refrain from acting). For example,with the current knowledgeof
pregnancyand child developmentwe might expectpregnantwomento stop smoking.
Prior to the extensiveevidenceof the potential dangersto the developingbaby,we did
during
but
to
smoking
pregnancy,
our expectationsof social
not expect woman give up
have
increased
knowledge.
time
changedwith
and
roles and responsibilities
With increasingscientific evidenceas to the factors, which contribute to disease
heart
disease,
individuals
in
to
and
vascular
might
we
expect
particular
generally, and
illness,
The
is
harm
behaviour
that
their
which
may
result,
a
accordingly.
modify
30
affects not only the individual, but also their close community and membersof their
family and friends. Can people expect support from others
and from limited health
if
care resources, they do not demonstrateresponsibilityto maintaina healthylifestyle,
known
avoid
risks and co-operatewith advice and treatmentfrom health care
professionals?
documents
importance
individual
the
government
emphasize
Xecent
of
responsibility:
'individuals
have a responsibility for their own health. Everybody shouldtry to look
...
better.,
by
themselves
after
not smoking,taking more exercise,eatingand drinking
(Department
is
Health
1999:
improving
There
that
sensibly'
of
recognition
vii).
also
health is not solely an issueof personalresponsibility,rather it is a balancebetween
individuals
do
factors
can and should and wider
what
suchas air pollution,
disorder,
low
housing.
Nevertheless,
the
and poor
unemployment,
wages, crime and
in
key
improve
health
the
targets
the
the
to
areas
proposals
of
nation and achieve set
for
individual
do.
'Individuals
to
the
can
are central our new vision
rely partly on what
better health. Peopleneedto take responsibilityfor their own health- andmanymore
improve
individuals
is
their
doing
There
that
can
realisation
clear
a new and
are
so.
health,by what they do and the actionsthey take' (Departmentof Health 1999: 8).
for
do
their
individuals
here
take
is
There no suggestion
that
responsibility
not
who
lifestyle should forfeit the right to health care. However Emson (1992: 10) suggests
health
in
to
that 'we have arrived at the point when eachstatementon rights relation
follows
'
It
duties
by
be
and responsibilities.
care must accompanied considerationsof
individuals
be
those
to
that we might wish to explore whether priority should given
between
be
have
lifestyle,
to
healthy
made
have
choices
when
a
maintained
who
for
distinct
the
There
two
prioritizing
for
reasons
are
scarceresources.
patients
fair
to
it
those
to
Firstly,
at
all
not
are
who
individual:
prefer
only
seem
may
prudent
19Key areas include cancer, coronary heart diseaseand stroke, accidents and mental health'
31
blame for their illness or injury and secondly,it
may encouragepeopleto be
20
responsibleand hencesaveresourcesfor those whose illness/injury are undeserved.
Hence, individuals who continue to abusetheir health and ignore
adviceabout how to
prevent diseaseand injury may have a weaker claim to limited resources.
However, before acceptingthat the responsibleindividual shouldbe given preference
in accessto scarcemedical resources,we should considersomeprelin-finaryquestions.
VVhichcriteria could be used in practiceto determinewho shouldbe treated,when it is
not possibleto treat everyone? Which criteria shouldbe used? I wish to consider
it
be
justifiable
whether would
and fair to use medicalneed,clinical and cost
desert,
both
for those who are chosen,and for thosewho
effectiveness,age, as well as
denied
first
discussion
This
in
the
treatment.
take
are
choice of
place chaptertwo.
will
In chapterthree, I will examinesomeof the various theoreticalaccountsof distributive
justice in,order to determineif any of theseenableus to establisha fair way to allocate
key
four,
I
health
between
In
turn
to
other
will
patients. chapter
care resources
scarce
lifestyle,
dissertation:
for
Do
their
this
peoplemakevoluntary choicesabout
questions
behaviour?
In
health-related
for
hold
it
does
their
them
to
responsible
make sense
and
health
five,
I
the
careprofessionals
governmentand
will examinewhat actions
chapter
lifestyle?
healthy
I
then
to
to
will
trying
take
persuadepeople adopt a
when
should
health
in
inherent
care
allocates
policy,
which
any
problems
some
pragmatic
examine
individual.
I
Finally,
lifestyle
case
the
some
review
the
will
to
of
resourcesaccording
has
lifestyle
to
occurred.
studieswhere rationing according previous
20However, people who do not change their behaviour becauseof the fear of becoming ill or injured
They
because
the
threat
behaviour
medical
care.
of
of
of
withdrawal
their
to
be
change
unlikely
may
immediate
live
for
thrill.
the
future
and
their
generally
may be unconcerned about
32
Chapter Two
RATIONING
SCARCE RESOURCES IN HEALTH
EXAMINATION
OF THE POSSIBLE CRITERIA
2.1
Criteria for rationing in health care
2.2
Medical need
2.3
Patient Desire
2.4
Clinical and Cost Effectiveness
2.5
Age
2.6
Waiting lists and lotteries
2.7
Desert
2.8
Conc sions
33
CARE - AN
2.1
Criteria for rationing health care
In this chapter, I will examinea number of criteria, which could be
usedto allocate
scarceresourcesin health care,,including medicalneed,patient desire,clinical and cost
effectiveness,age, waiting lists, a lottery systemand desert. I hopeto demonstrate
that a pluralist approachshouldbe usedin decisionsabout which patient is treated. I
will arguethat somecriteria including medicalneed,clinical and cost effectiveness,and
desire
directly
patient
are
relevantto thesedecisions. In addition, lifestyle and agemay
be indirectly relevant if they affect the probableclinical outcomesof treatment.
I have arguedthat rationing is inevitablewithin the NHS, where rationing is definedas
the withholding, or delaying,of beneficialtreatmentprimarily becauseof limited
'
health
issue
is
but
how
In
fairlY.
to ration
resources.
care,the
not whether to ration,
It is therefore desirableto exanfinethe various criteria on which rationing decisions
have beenmade,,and could be made,in order to determineif they would be fair both to
first
it
those
to
the
treatment
are
not.
might
choice,
and
who
of
patientswho are given
limited
distribute
is
just
happen
that
to
that
there
resources,
a
and
workable
way
so
doesnot take into account previous lifestyle and behaviour. However, there may be
be
it
limited
therefore,
resourcesand may
no simple criterion on which to allocate
justifiable to adopt an eclectic approach,using a numberof variables,including even
lifestyle, in order to choosewhich patient shouldbe given limited resources.
This discussionpresupposesthat every effort hasbeenmadeto raiseextra resources,
by
improving
the
health
increasing
to
by
or
the
provision,
care
overall allocation
either
(1997:
13)
Paper
White
that
NHS
While
the
suggests
the
service.
efficiency of
it
that
'according
be
to
appears
treated
NHS
alone',
in
need
and
need
will
patients the
in
been
in
have
the
practice.
past,
adopted
and
are,
criteria
a variety of
' Hunter D. J. Rationing Health Care: the Political PerspectiveIn British Alledical Bulletin 1995,51
(4)877
34
2.2
Medical Need
The White Paper, 'The New NHS. Modern. Dependable' (1997: 13)
statesthat
patients in the NHS will be treated 'according to needand needalone.' Many doctors,
accordingto Gillon (1985: 95) prefer 'medical need' asthe criterion on which to
decidewho should be treated when resourcesare limited. Sinceit
makesno senseto
treat people unlessthey have a medicalneed,it is surely a relevantand appropriate
criterion on which to allocatehealth care. However,,I suggestthat 'need alone' is not
sufficient to determinewhich patient shouldbe treated, when not everyonecanbe
treated.
Firstly, I have proposed that it is not always possible to treat everyone according to
their needsbecauseof limited resources(Chapter 1.4). Secondly,it may not be
reasonableto treat everyoneaccordingto their needs.The capacityof modem
life
is
intensive
beds
to
today
that
medicine preserve
so great
care
andtechnological
treatmentscould use vast amountsof both financial and staffing resources,to the
detriment of other welfare needsof society. Excessivespendingon healthmay reduce
the availableresourcesfor education,housing and safetransport, all of which may
impinge on the health and well being of individuals.
Thirdly, in the area of health care, where there are ongoing innovationsand new drugs
becomeavailable,it is difficult to determinethe scopeof medicalneed. Mason and
McCall Smith (1994: 257) describeneedas an 'imprecise' and 'elastic' concept. It is
it.
fall
but
imprecise
things
that
under
rather what
is
not,,though the concept
According to Daniels (1981: 158) health care needsencompass'those things we need
in order to maintain, restore or provide functioning equivalents(where possible)to
difficulty
definition
Consider
'
functioning.
the
to
this
of
applying
normal species
determinewhat counts and what doesnot. For example,do treatmentsfor infertility,
35
complementarytherapies,lifestyle drugs, and certain psychiatricdrugs
satisfymedical
needsor are thesetreatmentsmerely a responseto patients'desires?If thesebroader
included
needsare
as medical needs,it will be impossibleto meetthem within the
budget
for health. Further criteria will be neededto determine
existing
which
treatmentsshould be offered.
Finally, if the NHS is committed to allocatingtreatment accordingto
needand need
how
alone,
should decisionsbe madebetweenpatientswho have similar needs?Can
one assesspatients according to the seriousnessof their needs,or the immediatethreat
to life? This would favour the allocation of resourcesto those patientswho needlife
savingtreatment, with an associatedloss for other areasof care. Even if needis acute,
should medical treatment always attempt to meet critical life threateningneedsin order
to prolong life, or doesthis dependupon other factors suchasthe predictedoutcomes,
clinical and cost effectivenessand potential quality of life for the patient?
I suggestthat need cannot serveasthe only criterion in distributing limited medical
resourcesbetweenindividuals. If it is acceptedthat other criteria will inevitably come
is
it
include
to
reasonable
into play,
amongsttheseothers not only clinical and cost
determine
lifestyle,
in
but
to
order
effectiveness also considerationssuchas age or
be
which patient should treated?
The distribution of limited health care resourcesbetweenindividualswho have similar
it
for
do
have
treatment
is
We
and
equalneeds medical
not all
medicalneeds complex.
if
(1995)
Swift
for
that
the
makes point
equal shares.
would not make senseto argue
in
itself
it
does
health
the
than
characteristics
affect
not
me,
care
more
get
people
other
health
I
health
I
I
that
that
the
need
the
care
can
get
all
to
get.
care
the
of
me
of
value
health
in
Only
the
than
if
case
of
more
me.
getting
are
others
even
as a citizen
level;
basic
have
the
that
to
at
everyone
equality
should
argue
wish
we
might
education
36
for example,everyoneshould be informed of the merits of a healthydiet
andthe risks of
smoking.
The assessmentof 'medical need' will inevitably fall to the medicalprofession,who by
merit of their education and expertiseshouldbe best qualifiedto determinemedical
need and clinical outcomes. For certain patientsit may be decidedthat surgeryis 'not
indicated.
-)2
Hope,,Sprigingsand Crisp (1993: 379) suggestthat this
clinically
indicate
it
is
in
best
interests
the
that
to undergosurgery.
not
patient's
expressionmay
The probable outcomesare not favourableand might lead to poor quality of life or even
death,which outweighs the possiblebenefitsof the operationfor the particular patient.
Nevertheless,it is never possibleto look into the future with absolutecertainty andin
in
decisions
fully
involve
is
important
it
the
to
aspossible any
patient as
current practice
in
different
have
Individuals
values
will
about the treatment and possibleoptions.
inherent
for
the
is
the
them
risks
are
worth
and whether
assessingwhether surgery right
be
based
benefits.
Decisions
should
alone
and
need
clinical
on
not
should
anticipated
involve input from the patient about what is right for him or her.
This is well illustrated by a casein practice where a young marriedwomanwith two
decided
Medical
kidney
a
was
she
transplant,
staff
young children was offered a
did
because
to
declined
not
wish
the
transplant
she
but
their
to
she
surprise
priority,
home
its
on
well
managing
was
she
when
risks
associated
undergo major surgerywith
future
distant
in
have
the
a transplant
dialysis. Sheexplainedthat shewould rather
improved.
had
knowledge
transplantation
the
about
her
children were older and
when
life
life
of
quality
judgements
the
expected
or
of
quality
Wheneverpossible,
about
indicated'
'Not
may
the
379)
that
clinically
phrase
2 Hope, Sprigings and Crisp (1993:
suggest
for
the
patient.
there
resources
doctor
available
no
are
means
the
actually
be
when
sometimes used
for
'stop
'hide
up
doctor
the
truth'
covering
should
and
the
that
may
63)
claims
Indeed Ward (1986:
have
doctors
tell
to
difficulty
patients
be
'
There
when
genuine
a
may
health
inadequate
service.
an
this
While
this.
condone
to
not
may
try
we
they
funds
avoid
may
and
that there are no available
it
1985),
Higgs
1991,
(Jackson
honesty
importance
patients
with
the
of
behaviour, nor underestimate
is
discussion
often
in
not
rationing
of
where
a
climate
is an understandable approach particularly
explicit.
37
LFi:np i mmirmplTv
I 119RARY
be
left
to the one personwho knows best about the patient'splans andfeelings
should
namelythe patient.
In essence,medical needis one of the relevant criteria in the distribution of healthcare.
However, it is not the only morally relevant criteria becauseit is impossibleto meet all
health care needs,and anywayit is unreasonableto attemptto meetthem all. Other
be
including
criteria should also considered
clinical and cost effectivenessand patient
health
distributed
is
If
care
preference.
accordingto 'need andneedalone', as
in
documents,
suggested recent policy
severalquestionsremainoutstanding. For
drugs
NHS
Do
the
meet?
suchasviagra, and other
example:what preciseneedsshould
3
desires?
for
frail
long
drugs
Is
'lifestyle
the
term
care
meet medical needs,or patients'
is
it
immobile
a socialneed?
elderly a medicalneed or
and
Chapter
7.5.
drugs'
'lifestyle
see
For further discussion about
38
2.3
Patient desire.
In the majority of casesthe doctor and the
patient will negotiatecommonaims of
treatment attempting to meet both medicalneedsand patient desires. V;Mle
there is
an
increasingemphasison patient autonomy
4
health
within
care, and patientsshouldbe
given a clear explanationof any proposedtreatmentbefore they consentto care,
respectfor autonomy does not imply that patientscan demanda particulartreatmentor
investigation. Rather respectfor autonomyin the medical
context impliesthat a
competentpatient's refusal of treatment shouldnot be overridden.
Patients,doctors and the public may have different perspectivesof what constitutes
a
legitimate claim on the health service. While the patient may feel that the treatmentfor
infertility or varicoseveins is of paramountimportance,local managersin the NHS
include
the provision of suchtreatmentin their services,becausethey do not
may not
classifythese conditions as medicalneedsor priorities.
It is sometimesdifficult to distinguishbetweenpatient desiresand patient needs.' If a
desires
patient
certain physical treatment; for example, cosmetic surgery or treatment
for infertility, the consequencesof delaying or refusing treatment may have significant
psychologicaleffects for the patient. Psychologicalstressmay leadto mentalillness,
is
illustrated
in
This
turn
a casestudy
presentas a clinical need.
well
which can in
denied
initially
by
(2000:
McIver
30)
Ham
gender
of a patient who was
presented
and
for
The
the
the
treating
claim
surgery
patient and supporting
psychiatrist
reorientation.
five
is
in
fear
I
'without
to
the
that
she at great risk of suicide,unable
operation
wrote
the 'halfway' situation.'
'Beauchamp and Childress (1989), Gillon (1985), Edwards (1996)
5 Wiggins (1985) discussesthe distinction between needsand desires. Plant (1991: 184-220)
discusseshow we might distinguish between needsand wants and examines the nature and claim of
distinction
between
(1986)
the
Wilson
patients' wants and patients'
also
examines
needsgenerally.
interests.
39
Nevertheless,doctors can be justified in refusing to provide
what a patient requests
and I have previously indicated that any legal, or moral right to health care on the
NHS, is not absolute.6 If a patient requestsan expensivebut beneficialtreatmentor
drug, the doctor can refuseto provide such care on the basisof cost or scarce
resources. Doctors work with limited resourcesand there may be competing
obligations to treat other patients.
However, Hellman (1997) suggests that there may be potential problems, such as the
loss of trust, if the doctor considersthe issueof societalcost, while making decisions
individual
the
about
care of
patients. He goes on to suggestthat there aretwo roles
for the physician. As an agent of society, the physician must consider the greater good
directives
limitations
be
involved
in
development
the
on
and
of guidelines,
and
best
doctor
in
As
the
the
the
to
shouldact
physician
individual patient,
practice.
interestsof eachpatient, within the linuts of availableresources.
In essence,patient desiresshouldbe consideredin decisionsabouttreatment.
However, patients are not entitled to demandparticular treatmentsor care,at specified
be
desires
Patient
NHS.
times on the
are one of a numberof criteria, which should
included in decisionson resourceallocation, alongsidemedicalneed,clinical and cost
effectiveness.
force
in
the
to
her
father's
the
despite
NHS
courts,
efforts
6 Child b was not treated on the
wishes, and
in
doctors
Court
High
that
The
refusing
act
properly
recognised
treatment.
doctors to continue
doctors
in
the
into
this
who
case
financial
although
consideration,
in
constraints
treatment and taking
by
they
considerations.
insisted
that
only
clinical
b
moved
Child
were
refused to treat
40
2.4
Clinical and Cost Effectiveness
Recent governmentpolicy (NHS Executive 1999: 8) has
emphasizedthe importanceof
clinical and cost effectiveness.While the principle of effectivenesssuggeststhat
resourcesshould be allocatedto those treatments,which are clinically effective,the
notion of cost effectivenesssuggestsresourcesshouldbe allocatedto thosetreatments,
benefit
for cost.
which will maximize
Clinical effectiveness,basedon the availableresearch,remainsan important aim in the
medicaltreatment of patients. It is surely one of the principles,which shouldbe
in
considered the allocation of resources. Hunter (1997-.76) suggeststhat the drive for
level
NHS
the
the
clinical effectivenessnow permeates
of rhetorical aspiration. A
at
(including
the NHS Centreof Reviewsand Dissemination
number of researchcentres,
findings
for
Cochrane
Centre)
disseminate
UK
the
and
and guidelines effective
practice.
The recently establishedNational Institute for Clinical Excellence(NICE) will produce
inform
based
disseminate
those
to
professionals
support
and
guidelines
evidence
and
decisions
the
have
the
to
use of new and
patients
and
of
management
about
make
who
health
basis
On
then
the
their
the
secretary
of
appraisal,
existmgtreatments.
flu
drug
in
NHS
the
doctors
the
shouldnot widely prescribe anti
recommendedthat
been
has
Relenza
drug
because
not
the effectivenessof the
was uncertain.
relenza,
banned,but doctors should take the guidelinesinto accountwhen exercisingtheir
is
it
for
is
NICE
While
judgement.
not explicitly responsible rationing,
professional
in
the
of
certain
their
withdrawal
result
could
the
recommendations
that
of
effect
clear
/
basis
NHS,
from
the
the
forms of treatment,
of clinical outcomesand or cost.
on
to
treatments
those
to
which are
only
resources
allocate
It seemsentirely appropriate
41
effective and one might question any suggestionto do otherwise. However, in
practice
there are someproblems with the idea that medical care
shouldbe allocatedstrictly
according to clinical effectiveness.Many procedureshaveuncertainand unproved
outcomesin health care. Bottomly (1993: 29) suggests'Treatmentsthat were
previously common havebeen shown to be either ineffective or overused for
examplegrommets or tonsillectomies.' As a result the frequencyof theseprocedures
has declined. However, in someindividual cases,theseprocedures
are effectiveand
in
improved
health for the patient, sinceit is often difficult to apply general
will result
guidelinesor rules to particular cases(Beresford 1991). Medical researchdoesnot
produce unambiguousresults and it appearsthat there are often patientswho prove to
be the exceptionto the rule. Patientsare not a homogenousgroup andthey will
respondto treatmentsand drugs in a variety of ways.
If doctors and / or managersdecideto allocatemedicalresourcesaccordingto clinical
effectiveness,those treatments,which arejudged to give somesmallbenefit only,
could be restricted. One might suggestthat this is not rationing at all, becauseif a
benefit,
is
being
denied
intervention
is
limited
then
medical
no one
of
what they need
(New and Le Grand 1996). However, it is rare to be ableto predict future outcomes
for
benefits
health
the
there
significant
and
are
often
certainty
of
absolute
care with
17
'the
(1995:
is
83
5)
if
Hence,
Weale
that
there
states
no completecure,
patient, even
is
it
that
not
pervasiveuncertainty about various aspectsof medicalpracticemeans
first
ineffective
the
the
to
priority of
procedures
elimination of
always easy make
11
health
care rationing.
prudent
for
is
it
is
that
In addition,
clinical effectiveness not alwaysa priority
relevant to note
is
The
treatments
recognized.
of
well
effect
certain
their
placebo
relatives.
or
patients
families
done
being
is
their
to maintain
The idea that something
allows patientsand
in
treatment
that
is
result
may
unexpectedpositive
hope and there perhapsa chance
42
results, even if researchsuggestsit is unlikely in the majority of cases. Attention,
care
and an attempt at treatment may in themselvespromote a senseof
being
for the
well
patient, even if clinical trials suggestthat the physicalimprovementsmay be
minimal.
It is not clear that the reduction of inefficient procedures
will amelioratethe needto
health
in
ration
care the NHS. Throughout the history of the NHS there hasbeenan
demand
for new servicesand more expensivetreatments. New drugs,
increasing
such
beta-interferon
for the managementof multiple sclerosis,and xenicalfor
as viagra,
obesity, suggestthat demandwill continueto increaseandthat the needto make
difficult decisionsabout who receivescarewill remain.
For example,donepezilis a new drug for the treatmentof Alzheimer's disease,which
licensed
for
in
was
prescription the UK from April 1997. Benbow, Jonesand Jolley
(1999: 26) suggestthat the clinical effectivenessof this drug is variable:up to onethird
improvements,
of patients show
approximatelyone third of patientswill maintaintheir
function rather than decline,and roughly one third will declineas expected. Sincethe
drug
be
this
to
cost of
is estimated
about fl, 000 per year, per patient, and Alzheimer's
diseaseis not uncommon,there hasbeenreluctanceby somehealth authoritiesto fund
this treatment (Benbow et al 1999). It appearsthat rationing is occurring in some
benefit
Yet
to
the
research,would
somepatients,according
geographicalregions.
from this drug therapy.
Economists., such as Williams (1992), are concerned not only with clinical effectiveness
but also with cost effectiveness. The aim is 'to measurecosts and benefitsand choose
for
benefits
health
that
the combination of
availableresources'
maximizes
care
(Donaldson 1993.8 1). Greater financial awareness,due to the devolvedresponsibility
increasing
business
holding
fund
the
budgets
for the
and economic
to the
practices,and
doctors
have
their
the
of
more
aware
of
effects
wider
trusts,
made
the
values of
43
decisions. It is surely naive, and unethical, for
professionalsto makechoicesabout
treatmentswithout consideringthe wider implicationsfor resourcesgenerauy
and the
availability of resourcesfor other patients, and future patients. Williams (1992: 7)
'anyone
states
who saysno account shouldbe paid to costsis really sayingno account
be
should paid to the sacrificesimposed on others'. He suggeststhat there canbe no
for
ignoring
the effects of your actionson other peopleand he
ethical grounds
concludesa caring, responsibleand ethical doctor hasto take costsinto account.
While economistsmay be ableto measurethe costs of the service,and evaluatethe
in
costs of proposed changes the service,it is still necessaryto define and measurethe
benefits. Sincethere are real difficulties in defining health,(which will be discussedin
health
in
5.1)
the
chapter
and objectively measuring outcomesof
care,particularly
terms of patient well being, it may be more difficult to evaluatethe benefitsof health
care.
Harris (1996) discussesthe precisemeaningof 'benefit' within the context of health
by
is
be
delivery,
there
may rival conceptionsof what meant
and suggeststhat
care
benefit. Firstly, patients may want what is most beneficialfor themselvesin terms of
life.
In
best
the
longest
or
providers,
contrast,
the
of
quality
possible
and
achieving
have
in
be
those
health
a
funders, of
patientswho
selective choosing
care may want to
in
do
indicates
terms
and
they
survival
that
overall
of
well
will
prognosis,which
recovery rates.
Harris (1996: 273) asksthe question: Shouldthe patient with a ninety per cent chance
if
forty
they
are
be
chance,
to
the
cent
per
a
with
patient
of recovery always preferred
in
is
the
health
If
for
this
answered
for
question
in competition
care?
resources
have
high
be
judged
to
a
and
risk
is
those
it
are
that
who
patients,
clear
affirmative,
This
to
disadvantaged.
be
systematically
appear
would
poor prognosis, will
44
disadvantagethose people
have
who
existing chronic illness,
suchas diabetesand
hypertension,which seemsto be
unfortunate, and contrary to the statedaims
of the
NHS.
The 'quality adjustedlife year' or QALY, as describedby Alan Williams (1985), is
a
meansof evaluatingthe benefits of health care,both in terms of predictedquality life
of
length
and
of survival. A cost-effectivemedicalprocedureis one where the cost per
QALY is low. However, severalethical concernshavebeen
7with
raised,,
regardto the
QALYs
in practice. For example,the applicationof a QALY approach
use of
could
in
result reducedresourcesfor certain vulnerablemembersof society. Sinceold
people generallyhave a shorter life expectancythan the young, they will havefewer
yearsto gain from treatment, and will thereforebe disadvantagedby any assessment
of
QALYs. Disabled people may also be disadvantagedby subjectivejudgmentsabout
their quality of life.
Michael Lockwood (1988: 45) suggeststhat the QALY approachmay seemintuitively
because
"To
the
unjust
principle
eachaccordingto what will generatethe most
QALYs' is potentially in conflict with the principle 'To eachaccordingto his need.
Conditions that can be treated cheaply,with a high probability of success,will score
favourably on a QALY assessment.Yet suchtreatment shouldnot alwaysbe given
intensive
lifesaving
The
treatment.
care
priority, over more costly
patient who requires
treatment may havethe greater medicalneed,and may require lifesavingtreatment.
Public opinion seemsto support the rescueprinciple, which impliesthat we shouldtry
to save people if their illness or injury is life threatening. Accordingly, it is justifiable
heart
has,
for
individual
the
to
attack, and
to give priority
example, suffered a
who
financial
be
if
to
treat
the
a
resources
could
same
used
even
requires coronary care,
individuals.
for
less
a greater number of
urgent conditions,
number of
7 SeeHarris 1987, Harris 1995, Rawls 1989, and Haydock 1992 as examples of articles which
QALYs
ethical
concerns,
various
raise
and
the
of
notion
critique
45
Of course, somelives may
unfortunately be too expensiveto rescueand while great
importance is attachedto savinghumanlife,
there is no absolutelegal or moral
obligation to rescuean individual. Emergencycare canbe extraordinarily
expensive
and when it is, the rescueprinciple may be overriddenin the public interest, because
or
of competing obligations.
In essence,both clinical and cost effectivenessare
considerations,which shouldbe
included when making decisionsabout the allocation
of scarcemedicalresources.
They are not, however, the only relevant considerationsand I
suggestthat they should
be consideredwith other criteria suchas medicalneedand patient
choice. QALYs will
indication
give an
of what proceduresare cost effective and as suchshouldbe included
decisions.
these
within
In this thesis, I wish to examinewhether the allocation of healthcareresourcesshould
be partly dependentupon previous or current lifestyle. It is evidentthat certain
behaviour, including smoking, and continuedexcessiveeating,leadingto obesity,may
affect the recovery rates from surgery,and may therefore affect the clinical and cost
Thus,
be
treatments.
effectivenessof certain
somepatientsmay chosen,or not chosen,
partly becausetheir lifestyle has affectedthe probableclinical outcomesof treatment.
This is not discrimination on the basisof lifestyle itself, but rather on the predicted
for
individual.
This
that
treatment
particular
will
clinical effectivenessof
be justifiable in somecasesand shouldbe distinguishedfrom a decisionto allocate
for
former
unhealthyor
medical resourcessimply, or evenpartly, as a punitive measure
behaviour.
risky
46
2.5
Age
Chronological age is sometimesused,' as one the
of
criteria in decisionsaboutwhich
individual should be treated when resourcesare limited
and not everyonecanbe
treated. While age is not officially identified as an obstacleto treatmenton the British
NHS (Aaron and Schwatz 1984: 34) (Departmentof Health 1994),it is
evidentthat
doctors do sometimesselectyounger patientsin preferenceto older
patients. The
restriction of particular treatmentsto those individualswho are, for example,underthe
age of sixty-five, may be convenientand easyto administer. It may, however,be
difficult to justify as a policy.
A variety of argumentsare presentedto justify the idea that there shouldbe limits to
for
treatment
the elderly. Firstly, by treating the youngerpatient, more years
medical
future
life
be
is
important
(This
in
of
wiH normafly saved.
an
consideration the
it
QALYs.
)
it
is
be
However,
that
assessmentof
worth noting
would more appropriate
to baserationing decisionson 'biographical'9age,generalfitness and health status,
fife
in
is
there
the
than
chronological age, since
expectancy
rather
enormousvariation
for individuals of the same chronological age. Callahan (1987: 164) suggeststhat age
is 'the equivalent of such typical medical indicators as weight, blood pressure, or white
'
the
These
context of an overall
evaluated
within
are
usually
cell count.
variables
health.
indicator
in
isolation
they
of
are a poor
physical assessmentand
Secondly,Daniels (1985) arguesthat limited medicalresourcesshouldbe restrictedfor
does
He
the
for
free
in
the
problem
not
visualize
to
the elderly order
young.
resources
but
individuals
between
distribution
old
and
young
of
groups
competing
of
as one
8Examples of rationing medical resourcesaccording to age are presentedin chapter 1.3.
9 Rachels (1986: 50) makes a distinction between being alive (in the biological sense)and having a
but
in
be
Thus
valuable
coma,
a
a patient can alive, and unconscious
Iffie (in the biographical sense).
indication
irreversible.
is
Biographical
if
of stage
the
has
an
age gives
coma
biographical life
ended,
from
differ
it
age.
chronological
life
may
and
reached
of
47
he proposesthat the issueshould be
understoodin terms of allocatingmedical
resourcesthroughout the duration of the samelife. If you havelimited
medical
resources,you might chooseto allocate a greater proportion within the
early or middle
agedyears,with a correspondinglyreducedamount in later life.
Daniels adopts a Rawlsian approachin order to determine just distribution
a
of
resourcesbetweenthe various stagesof life. What, he asks,would the prudent planner
choosein a situation not dissimilarto Rawls' original position? 10Prudentagentsmust
attempt to determinewhich principles shouldgovern the distribution of healthcare,
knowing nothing of their own age,family situation, health status,genetichistory,
socioeconomicposition, and suchlike. If resourcesare limited, Danielssuggeststhat
deliberators
prudent
would give priority to enhancingthe individuals' chanceof
reachinga normal life span,rather than extendingthe normal life span. In addition,
they 'would seeka health-careand long-term care systemthat protectedtheir normal
opportunity range at each stage of their lives' (Daniels 1985- 103).
According to Daniels, a greater proportion of medicalresourceswould thereforebe
allocatedto those conditions, which occur in early life, rather than on preservinglife
life
be
its
Expensive
treatments
after normal span.
might restrictedto younger
saving
(Daniels
is
denied
to
those
the
not
age of seventy,seventy-five.
patients, and
after
)
the
specific about
preciseage.
While Daniels suggeststhat medicalresourcesshouldbe allocatedto protect the
it
life,
is
during
that
there
will
of
not
obvious
each
stage
range
normal opportunity
Daniels'
For
be
this
to
approach
goal.
example,
always enoughresourceseven achieve
does not clarify whether infertility treatment shouldbe provided, and suchtreatment
10Daniels himself suggeststhat there are important differences between his view and Rawls' veil of
than
adopting
maximising
rather
straightforward
reasoning
use
The
should
ignorance.
prudent agent
See
Daniels
1988:
88-89.
the
off.
the
of
worst
position
a strategy to maximise
48
important
could meet
needsnecessaryto maintain normal opportunitiesfor those of
childbearing ages. in reality, choicesmay still haveto be madebetweencompeting
defensible
be
in
patients and
criteria will
required order to justify the decisionsmade.
In addition, Daniels does not elaboratewhat precisepolicies could be implementedin
based
into
in
to
order put age
rationing
practice a just way. Battin (1987) suggests
that while we may hope that agebasedrationing and denial of treatment,or indeed
delay in treatment, may bring about an earlier peacefuldeath,this is not guaranteed.
Rather patients might have a prolonged period of morbidity and chronic disabilitywith
discomfort.
pain
associated
and
Thirdly, Callahan(1993) proposesthat age could be used as a standardto restrict the
He
life-extending
high
treatment.
technology,
presentsvarious
allocation of expensive,
from
be
form
idea
the
treatment
this
the
that
to
withheld
of
should
principles support
longer
life
has
lived
'After
span,medicalcare shouldno
out a natural
a person
elderly:
be orientatedto resisting death.' (Callahan1987:25) Hencewhen a personhas
be
death
late
as
accepted
should
eighties,
early
or
seventies
say
reacheda certain age,
life
their
have
life.
Individuals
usually accomplishedmost of
the normal course of
is
death
fulfilled,
been
have
that
or
untimely.
premature
not
so
goals and opportunities
but
however
for
be
old,
Callahanemphasizesthat suffering should relieved the elderly,
be
technologies,
The
can
be
which
life
medical
of
existence
that
extended.
should not
health
duty
imply
does
professionals
life
care
on
a
the
not
the
elderly,
of
usedto extend
to use them.
developed
forty
countrieswill
yearsall
Callahansuggeststhat over the next twenty to
r7cý
for
health
the
burden
rising
financial
to
care
increasing
provide
faced
be
with an
have
do
While
the
a
elderly
in
acknowledging
the
population.
elderly
of
numbers
'Not
be
it
is
funds,
claim.
unlimited
an
cannot
and
not
public
upon
claim
substantial
49
is
only an unlimited claim likely to be utterly unaffordablelit would place
an unjust
burden on the young, whose taxes
must pay for sucha claim' (Callahan1993:24).
The aim of such a policy is not to reduce current
expenditurebut rather to control the
expectedescalationof future costs in a 'fair' and 'balanced'way. Indeed Callahan
emphasizesthese changesshould be implementedover a period of yearsso that
attitudes and expectationsabout old age can changegradually.
While Callahan'sargumentsare clear and the economicfigures may be convincing," it
is not obvious why this proposedpolicy, which gives priority to the young for life
is
fair
treatment,
to those of us who are inevitably approachingold age. Rather
saving
the policy seemsto be discriminatingagainstthe older membersof the population
because
they representan increasingpercentageof the total population and
merely
representa group who will probably make heavydemandson the health service. Is it
permissible to withdraw resources from the elderly, and continue to treat those
individuals who persistentlyignore health adviceby continuingto take risks with their
health,by pursuing activities suchas smoking, sunbathingor havingunprotectedsex?
If the current health statistics(Departmentof Health 1995) are to be believed,these
individuals will also make considerablefuture demandson the health service.
Hunt (1993) challengesCallahan'sargumentsboth on the groundsthere is little
He
that
the
grounds.
economic savingswould materializeand on ethical
evidence
from
the
treatments
elderlywould
that
medical
argues
a policy of withholding certain
ccurtail' the autonomy of the agedand would treat elderly people asthe meansto a
in
their
than
own right.
ends
as
greater social good rather
be
the
the
(199
1)
that
Similarly, Baumrin
autonomyof
elderly should
proposes
long
fulfil
life
live
be
their
to
as
and
as
plans
and
they
allowed
should
respectedand
11Grimley Evans (1993: 45) suggeststhat the implications for costs arising from the aging of the
is
often assumed.
as
British population are not as great
50
well as they can. In addition, Baumrin suggeststhat the doctor's normal
is
socialrole
to treat diseaseand trauma in order to improve our life
prospects. If this role is
perceivedto changeand doctors are seento be 'the arbitersof who shouldfive and
who should die' (Baumrin 1991: 159), it could lead to widespreadinsecurityand loss
of trust.
The most convincing argumentfor giving priority to the
in
young the allocationof
scarcemedical resourcesis the fair innings argument. Harris (1988) acceptsthat if we
have limited resourcesand are only able to treat one person(saythere is only one
ventilator or donatedliver) we mayjustifiably prefer to treat the youngerpersonin
preferenceto the older personwho hashad a good or fair innings. Lockwood(1988)
innings'
'fair
the
to justify treating the younger patient in preferenceto the
also uses
older patient. The younger person shouldbe given priority in order to maintainequity
in terms of years of life lived (Lockwood 1988: 50). 1 agreewith the fair innings
intuitively
death
because
be
the
to
argument
of a young personseems
a greatertragedy
than the death of an old person. There is a feeling of incompletenessand unfulfilled
it
is
difficult
dies.
In
to arguepersuasively
addition,
potential when a young person
fair
innings
the
argument.
against
However, the fair innings argumentshould only be appliedwhen there is a significant
individuals.
In
between
difference
the unfortunate and rare situationwhere
the
age
ZD
be
be
the
a
over
treated,
priority
given
should
sixteen-year-old
can
patient
only one
In
a
outcomes.
probable
clinical
and
needs
medical
similar
with
seventy-year-old,
be
it
the
but
to
forced
older
person
then,
rescue
unfair
would
only
choice,
situation of
had
has
/
he
die
let
innings
the
a
has
had
not
she
person
when
young
and
a good
who
f ag
ir innin S.12
121proposethat the fair innings argumentis only oneof a numberof relevantconsiderationsin
be
There
be
be
treated.
treated,
other
will
when not all can
decisionsaboutwhich patient should
decisions,
in
the
these
be
such
expectedsurvival of each
as
considered
factors, which should also
treatment.
of
outcomes
the
probable
patient and
51
In conclusion, age does not always reflect biological fitness, quality of life or indeeda
particular set of values, and it should not be usedmerely becauseit provides an easy
decisions
how
limited
is
to
It
to
way make
about
allocate
medicalresources.
clearthat
individuals,
fit
have
their
certain elderly
seventies,who are and
maintaineda
within
healthy lifestyle, will benefit from high technologicallife savingtreatmentsandmay
lives
for
have
be
People
their
to
treated
of all ages
a right
extend
many valuableyears.
individuals
and not as membersof a uniform class.
as
Nevertheless,age is sometimesdirectly relevantin decisionsabout who shouldbe
treated. When there is a significant age differencebetweenthe young and older
the
is
it
fair
the
to
have
I
to
on
person
that
younger
priority
give
proposed
patient,
Age
between
be
have
if
innings
to
fair
basisof the
patients.
made
argument, choices
has
if
for
of
be
indirectly
a
number
person
elderly
an
example
as
relevant
may also
is
latter
In
this
is
this
not
degenerativeconditions, and generallyunfit.
scenario,
but
'
the
of
'per
outcomes
based
predicted
on
rather
se,
age
on older
rationing
healthy.
individuals
for
those
who are not
treatment
52
2.6
Waiting lists and lotteries
Shortly after the NHS was establishedit becameevidentthat the demandfor
services
was greater than the capacity to treat patients.Generalpractitionersbecamethe
4gatekeepers'to specialistservices,making decisionsabout which patients
be
would
referred to specialistservices. When patientswere referredto hospital consultants,
they often had to wait weeks or months for their initial appointmentsand subsequent
treatments.Queuing for treatment is still evidentin the NHS today andthere is
"
debate
how
lists.
to managewaiting
considerable
about
In essence,if resourcesare limited, waiting lists may be seenas at leastas fair as many
of the alternatives. However, questionsabout who is eligible to Jointhe waiting list,
basis
be
the
and whether certain patients should given priority on
of needshouldstill
be examined. Accessto the waiting list is dependenton medicaljudgementand may
be
lifestyle
Factors
to
and agemay
suchas
vary according professionalevaluation.
list.
Harry
deny
delay
to
the
to
people access
waiting
or
used as criteria upon which
he
list
because
investigations
denied
I-hlick
the
to
a
was
and
waiting
access
was
F-P
died
before
he
receivingtreatment.
smoker, and subsequently
The present systemappearsto give priority to those who havewaited the longest,
basedupon the notion of 'first come - first served'. However, in practice,this will
in
later
help
the
disadvantage
those
point
a
at
who seek
penalizethe stoic and may
have
individuals
or
I
those
pain
illness.
that
severe
who
their
suggest
would
course of
less
be
fulfil
with
others
over
priority
given
their
should
to
activities
normal
are unable
into
taken
If
account,
immediate
not
less
are
of
need
considerations
needs.
severeand
13Department of Health Getting Patients treated., the waiting list action team handbook.
Department of Health 1999
53
then waiting lists may becomeunjust. It is of courseacceptedpracticeto ignore
lists
in
waiting
extreme cases,where a patient is acutelyill or collapses.For example,
the patient who has a myocardial infarct will be admitted accordingto need
irrespective of any waiting fist. Other patientswho are in severepain and havea life
threateningillness may also merit priority over otherswith lessurgent clinical needs.
Doctors can organizewaiting lists to reflect the differing needsof individuals,but this
introduces another criterion in decisionsabout which patient shouldbe treatedfirst.
Some patients with particular conditions are currently given priority within the system
be
For
time
may
guaranteed
a
period.
example,
and
a specialistappointmentwithin set
the NHS Executive (1998) has set a target of two weeks for a specialist to see a
for
is
breast
Currently,
this
not guaranteed patients
cancer.
woman with suspected
'targetting'
forms
This
of particular groups of patients
of suspectedcancer.
with other
beneficial
lead
identified
if
to
be
justified
treatment
there are
will
needsand early
may
be
it
is
to
However
that
there
mediacampaignsand
a
response
may
risk
a
outcomes.
politically motivated.
While the use of waiting lists is evident in practice,the allocation of medicalresources
1988:
Harris
60,
1988:
(Broome
is
lottery
theoretical
to
proposition,
a
a
according
distributes
lottery
A
in
resources
system
121) that is not reflected current practice.
randomly
(1,988)
Harris
being
treated.
individual
of
chance
equal
an
every
and gives
health
life
belief
the
that
of eachperson
and
has suggestedthat a lottery will reflect the
However,
is
respect.
to
and
concern
equal
that
entitled
eachperson
matters and
in
individual
problems
result
could
and
ignores
lots
drawing
the varying needsof each
lottery,
is
this
'who
to
what
9)
enter
(1992:
eligible
Williams
in practice.
questions
fail
if
lottery
to
win
the
how
you
re-enter
how
can
often you
the prizes are,
soon and
be
traded
given
(especially
tickets)
or
can
'tickets'
winning
the first time, whether
is
there
have
a
and
individuals
needs,
medical
equal
Since
'
rarely
away, and so on.
54
difference
between
life
life-enhancing
vast
procedures,the lottery system
savingand
has somelin-fitationsin reality.
55
2.7
Desert
Considerthe scenariowhere drunk driver
a
steershis car off the road and hits a
pedestrian,who is walking on the pavement, The driver andthe pedestrian both
are
injured
critically
and taken to the nearesthospital, where it is judged that they both
intensive
require
care treatment. There is only one bed available.
LeGrand (199 1) describessuch a situation and asks
who shouldreceivepriority for
treatment? He suggeststhat 'most peoplewould find it more acceptableto allocate
the bed to the pedestrian,on the groundsthat the driver was, to a large extent, at fault
for his predicament' (LeGrand 1991:103). This seemsto suggestthat the
pedestrian
deservesthe intensive carebed more that the drunk driver who hascontributedto his
(and
the other's) medicalneedsby his recklessbehaviour. He hasmadea choice
own
to drive having consumedexcessalcohol and he shouldacceptthe consequences
his
of
behaviour.
Glover (1977) presentsa similar casewhere there is only one intensivecarebed and
two people in need are brought into hospital. One is a bank robber andthe other is a
from
fire
heroicaffy
He
to
the
the
robber.
man who
aid of a pohcemanunder
went
hero
difference
favour
for
in
treatment
the
the
that
on
suggests
such a casewe would
life
is
directly
in
Glover
desert.
However,
to
this
the
that
case
risk
emphasizes
of
is
judged
being
this
to
the
not the sameas allowing generalcharacter
and
acts
related
in
be
dictate
the
to
allocation of
priority
given
should
who
evaluationsof moral worth
medical resources.
Nevertheless,these exampleshighlight that in extremesituations,desertmay be
decisions
In
in
factor
the
be
allocation of resources. practice,
a relevant
consideredto
be
bed
intensive
are
and
might
care
the
rare
other
criteria
one
receives
about who
56
consideredrelevant. People are unlikely to have similar medicalneeds,and one patient
be
may at greater physical risk than the other and
so merit the intensivecarebed on the
basis of acute need. Alternatively, if we saythat the driver the
of
car was nineteen,
while the pedestrianwas ninety-two, we may feel uncomfortableabout our former
decisionto treat the pedestrianin Intensive Care. Decisionsare multifaceted
it
is
and
obviously unrealistic to isolate one criterion, suchas desert,and excludeother relevant
factors.
If desertis sometimesa relevant criterion in acute situations,shouldit havea role in
determiningthe allocation of resourcesin other situations? Is it justifiable to give
healthy
to
the
priority
eater,who exercisesregularly and avoidsknown risks suchas
Should
individual
be
the
smoking and excessivesunbathing?
cautiousand sensible
dangerous
in
hang
the
taker
takes
sports?
part
gliding and
given priority over
risk
who
In other areasof our lives rewards and goods are distributedaccordingto desert- the
is
job
is
the
the
and
most successfulsportsman paid
well qualified person offered
handsomelyin prize money. Society generallyacceptsthe notion of desertas a fair
frequently
there
to
are
criterion on which allocate certain resources,although
fair
be
it
follow
It
that
would
argumentsas to the size of the allocatedawards. might
desert.
For
basis
the
example,,thosepeople
of
to allocate medical resourcespartly on
for
first
be
blood
donated
had
major surgerywhen
might considered
previously
who
had
Likewise,
those
for
previously
who
transfusionwas anticipated.
the need
if
be
themselves
they
donor
priority
given
might
registeredas a potential organ
required a transplant.
be
donation
'legislation
amended
governing organ
Jarvis (1995: 202) suggeststhat
donors
identify
themselves
potential
as
those
who
that
all and only
such
are
.........
'
He
that
would
a
scheme
transplant
such
claims
organs.
to
eligible themselves receive
in
differences
because
to
transplantation
access
ofjustice,
the
requirements
satisfy
57
programmeswould be basedupon relevant differences;only those who electedto act
as possible donors after their deathwould benefit from the transplantscheme.In the
light of the current shortageof donatedorgans,this
proposalappearsto havevarious
advantages;not least that it might increasethe availablenumberof organs,thereby
promoting the good for the population as a whole.
There are however, inherent problemsin this proposalpresentedby Jarvis. Onewould
needto be certain that the decision 'not to donateorgans' was deliberate.,well
informed and taken with an understandingof the consequences.Somepeoplemay
have
thought about donation, while others may havebeenencouragedto explore
never
the issuesand complete a donor card by an enthusiasticspecialist. In other words, the
decision"not to donate" should havebeenautonomous,and not the result of apathy.,
misunderstanding,or plain ignorance. If the 'modest proposal' as describedby Jarvis
it
introduce
behaviour
the
that
past choicesand
notion
were
were accepted, would
health
to
care resources.
acceptablecriteria on which allocate
It follows that those people who deliberatelyand knowingly choosean unhealthy
lifestyle could be held responsiblefor their fonner behaviourand forfeit subsequent
health care on the basisof desert. However, we needto examinesomekey questions
before acceptingthis suggestion. Do people really makevoluntary choicesabouttheir
lifestyle? Should doctors or any one else,makejudgementsabout the behaviourof
health
in
be
the
of
determining
scarce
allocation
priority
given
should
who
others when
care resources?
58
2.8
Conclusions
In this chapter, I have examinedsomeof the criteria,
which could be usedto select
patientswhen not all patients can be treated. I have arguedthat a pluralist approach
should be adopted,where medicalneed,patient desire,clinical and cost effectiveness
are always consideredin decisionsabout the allocation of scarcemedicalresources.
Other criteria such as age14and lifestyle choicesshouldalsobe considered, leastin
at
far
so
as they affect the probable outcomesof treatment. It follows that doctors
shouldbe involved in decisionsabout who shouldbe treatedbecausethey havethe
knowledge
relevant
about medicalneedsand probabletreatmentoutcomes.
Generalizationsabout people, such as the elderly or risk takers shouldbe avoided.
Just as ninety-year-oldsvary in their physicaland mentalhealth so do peoplewho
lifestyles.
We shouldnot assumethat smokerswin alwayshavepoor
adopt unhealthy
following
Some
clinical outcomes
surgery.
smokersmay exerciseregularly, eat a
healthy diet, have a stressfree lifestyle and only smokea limited numberof cigarettes.
In addition, they may be lucky and havegenes,which predisposethem to a long and
healthy life, so that the probable outcomesof surgerymay be favourable.
This pluralist approachto the allocation of health care resourcesmeansthat doctors
have
individual
To
decisions
difficult
they
have
to make
will
repeat,
cases.
about
will
to considermedical need,clinical and cost effectivenessand other criteria suchas age
However,
lifestyle
to
other
choices,where relevant probableoutcomes.
and
dependents,
are
postcode
geographical
of
number
worth,
social
as
such
characteristics
discuss
I
NHS.
these
the
to
the
will
not
of
principles
more controversial and contrary
here.
14 Where choices have to be made between patients of significantly different ages,the fair innings
in
there
these
However,
other
normally
and
are
choices
are
rare
be
practice,
relevant.
argument may
for
each
patient.
clinical
outcomes
in
probable
and
needs
differences
medical
relevant
59
In this thesis, I wish to examinewhether former and current lifestyle choicesare
directly relevant criteria to include in decisionsabout who shouldbe offered treatment,
when not everyonecan be given the treatment of first choice. I have suggestedthat
lifestyle can affect the outcomesof certain treatment and surgery,and it follows that
lifestyle can impact on the clinical and cost effectivenessof somemedicalcare, and
it
does
it
is
justifiable
include
in
decisions
This
to
so,
a
when
criterion
aboutrationing.
is not to suggest,though, that it is just to allocatemedicalresourcesaccordingto
former lifestyle 'per se', which is the central issueunder examinationin this thesis."
himself
both
injures
driver
drunk
who
15While I have noted that in extreme situations, such as the
in
factor
the
resources
be
scarce
of
allocation
to
bc
relevant
a
desert
considered
may
pedestrian,
a
and
differences
be
of
there
In
relevant
other
will
cases,
most
(Section 2.7), in practice these casesare rare.
be
decision
Hence
the
should
patient
about
which
outcomes.
clinical
probable
and
need
meAhcal
think
if,
in
Even
this
we
scenario,
be
these
likely
criteria.
is
to
on
made
allocated scarce resources
doctors
infer
should
that
to
policy
a
as
general
be
a serious mistake
desert is relevant, it may still
As
the
for
to
resources.
scarce
they
patients
select
apply
the
criteria
include desert per se among
law!
bad
hard
make
cases
saying goes:
60
Chapter Three
DISTRUBUTIVE
JUSTICE AND THE ALLOCATION
OF HEALTH
CARE
RESOURCES
3.1
Theories of distributive justice
3.2
The Libertarian approachto justice
3.3
The socialist approachto justice
3.4
Justice according to Rawls
3.5
The Communitarian approach to justice
3.6
health
justice
care
and the allocation of
Conclusionsabout distributive
resources
61
3.1
Theories of distributive justice
When there are limited resourcesand
we can only treat somepatients,what principles
should guide us in choosingwhich patients shouldbe given priority? This is difficult
a
question and a variety of different theories of distributivejustice, emphasisingdif(erent
principles, have been appealedto over the years. The various conceptionsofjustice
have implications regardingboth what people deserve
and what they are entitledto
'
The
possess.
various theories ofjustice will disagreein preciselywhat criteria should
be usedto differentiate individuals. For example:in essencethe Aristotelian
approach
would allocate benefitsaccordingto merit (Aristotle 1955: 178), while the socialist
principle, as describedby Nell and ONeill (1992) would allocatebenefitsaccordingto
need.
Bernard Williams (19,73)arguesthat if you differentiatebetweenindividualsandtreat
them in different ways there must be relevantreasons. In the allocation of healthcare
resources,it would obviously be unfair to discrin-finateon the basisof race,colour,,or
intelligence. In chaptertwo, I have suggestedthat relevantcriteria includemedical
desire
determine
I
to
need, clinical and cost effectivenessand patient
and wish
whether
the patient's lifestyle could be a relevant criterion to include in decisions. Williams
in
different
for
treating
that
the
the
people
reason
ways must
also makes
relevant point
be 'socially operative.' In reality, any policy, which allocatedresourcesaccordingto
2
in
fair
lifestyle, must be workable, and it must be possibleto implementit a
way.
In this chapter, I will attempt to clarify someof the prominent contemporary
health
implications
for
distribution
discuss
justice
their
the
care
of
and
approachesto
11 make this distinction becausesomeonemight be owed money according to a contract, but he or she
it.
deserve
might not
21 will explore the practicalities of implementing a policy to allocate health care resourcesaccording
6
in
lifestyle
to
chapter
62
resources.I have chosento discusslibertarianism;socialism;the social contract as
proposed by Rawls; and the communitarianapproachto justice. In eachcasethe
theory appealsto a different ultimate value.
I am not including discussionof the feminist perspectiveofjustice eventhough it
introduces somevaluableideas. Feministsare interestedin particular questions:
'What constitutesthe oppressionof women and how canthat oppressionbe endedT
(Kymlicka 1990: 238). Discussionfocuseson topics suchasthe private sphereof life
in the home, relationshipsbetweenmen and women, moral development,andthe
educationof children. It would be misleadingto suggestthat theseissuesare not
health
to
relevant
care provision generally. The roles and expectationsof doctors and
have
linked
/
female
historically
been
health
to
the
careprovision
role and
nurses
male
for women in a male dominatedframework shouldbe explored. However, the feminist
theory is not obviously helpful or relevantto the central questionof this thesis,which
lifestyle.
In
to
the
addition,
allocation of scarceresources,according
concerns
in
both
diverse
is
feminist
theory
premises and
extremely
political
contemporary
liberal
libertarian,
feminism,
(Hospers
1992)
socialist,
embracing radical
conclusions
femirusm.
and conimunitarian
discuss,
I
to
givesus
Each of the philosophicaltheories ofjustice, which am going
However,
theory
health
distribution
each
into
insight
resources.
the
care
of
some
to
is
inherent
there
solution
obvious
be
or
easy
to
no
to
and
problems
subject
seems
literature
The
justice.
of
views
distributive
a
variety
presents
current
the question of
of
range
and
the
society
pluralist
present
concerningthe notion ofjustice reflecting
by-passing
inevitably
relevant
mean
To
beliefs.
would
approach
one
rely on
political
theories
to
of
have
I
therefore
contrasting
ideas.
survey
chosen
material and
limited
in
the
to
theory
of
allocation
relation
justice
each
distributive
and will explore
be
lifestyle
I
a
would
In
whether
examine
also
will
health care resources. eachcase,
63
relevant criterion on which to ration scarcemedicalresources.
I make no attempt here to defendany one perspectiveofjustice in preferenceto the
alternatives. Neither do I aim to produce an in depth analysisof the conceptofjustice.
Rather, I discussthe theories in relation to the central issueof this thesis- the
individuals.
limited
health
between
is
My
allocation of
aim simplyto
care resources
life
is
based
the
allocation
partly on previous
style unjust according
establishwhether
to any of thesetheories.
64
3.2
The libertarian
approach to justice.
The libertarian conception of justice treats liberty
asthe ultimate political ideal, where
liberty is generally defined as the absence interference
of
or constraintsby other
people. 'Every humanbeing hasthe right to act in accordancewith his own choices,
unlessthose actions infiinge on the equalliberty of other humanbeingsto act in
accordancewith their choices' (Hospers 1992). Libertariansclaim that there are a
number of rights, such as the right to liberty, the right to life, and a right to property.
However, while theserights do entail a duty
duty
is
interpreted
the
be
to
that
usually
-
forbearance,
of
which meansthat other peoplemust refrain from violating your rights
or choices. For example:your right to life meansthat other peoplemust not kill you,
(unlessperhapsyou have consentedto suchan action and thereforewaived your right
in
as the caseof voluntary euthanasia).This meansthat the right to life, as perceived
by the libertarian, is not a right to receivehealth care and resourcesnecessaryto
preserveone'slife. There is no correspondingduty or obligation on othersto provide
suchcare.
Libertarians, such as Robert Nozick and the late Friedrich Hayek, advocatethat the
individual
be
from
function
to
the
encroachmentor
protect
sole
of governmentsshould
limited
'minimal
by
Nozick
to the narrow
state,
proposesa
aggression others.
functions of protection againstforce, theft, fraud, enforcementof contracts,and soon'
(Nozick 1974: ix), and he arguesthat the proper role of the stateis that of the
health
its
If
to
care,
nightwatchman. the statewidens powers provide services,suchas
lives
live
individuals
they
infiinge
it
to
their
the
as
choose,
then will
rights of
lives
live
beings
human
they
to
their
as
the
equal right of all other
compatiblewith
1992).
(Hospers
choose
(Sterba
in
libertarian
the
approach
Indeed, welfare rights are not generallyrecognized
65
1992: 6). The right to free medical care would inevitably result in somepeoplehaving
to be coerced into providing such a servicewith the associatedloss of their freedom,
be
which would
contrary to the ideal of liberty. Accordingly, there is no role for the
goverment to provide a health care servicesuchas the NHS. Coercionin the form of
for
finance
taxation
to
the servicewould not bejustified, even
a compulsory
all citizens
if there were someobvious benefitsfor certain individuals.
Libertarians could approve of a charitablehealth care systemfinancedby voluntary
donations,becausethis would not involve the coercion of individuals. Peoplecould
We
they
to
time
might still
and
specialist
services
chose
contribute.
when
give money,
feel that the rich or skilled were morally blameworthyif they refusedto help those
individuals who were unableto meet their basicwelfare needs,but this would not
justify coercion, accordingto the libertarian view. In addition, libertarianswould
health
in
free
that
the
to
peoplewould
so
care
market
generallysupport an extension
buy and sell health care provision in the sameway asthey buy and sell other
be
housing.
This
food
could
also
principle
and
computers,
as
such
commodities
blood,
kidneys,
human
or
sperm
as
such
the
organs
to
of
purchasing
and
sale
extended
bodies.
their
the
individuals
own
of
use
about
that
choices
make
could
eggs,so
distribute
be
their
doctors
to
services
Nozick (1974- 234) arguesthat
able
should
be
They
their
should
financial
to
goals.
own
meet
and
their
criteria
own
accordingto
The
they
choose.
free to set fees enhancingtheir salariesand ensuringtheir securityas
distribution
the
be
the
service,
of
to
control
able
providers of any service should
different.
doctors
no
are
terms
the
and
service,
of
choosingtheir clients and
'the
(1973:
240)
that
by
Williams
dismisses
the
Nozick
claim
In making this argument,
'
that
ill
health.
Williams
is
suggests
distribution
care
medical
of
proper ground of
basis
be
this
the
and
need
of
on
allocated
should
and
need
a
meets
treatment
medical
66
with referenceto no other criteria. He arguesthat if treatment costsmoneythen the
irrelevant criterion of financial wealth becomes
in
sianificant who can obtain treatment.
Distribution according to the economicmarket introducesdisparitybetweenthe
rich
and the poor, becausethere is a situation where peoplewith the samemedicalneedsdo
not receivethe sametreatment. Williams, like Aristotle, claimsthat if men aretreated
in different ways there shouldbe a relevant reason. He concludesthat in the
distribution of medical care, financial wealth of potential patientsis not a relevant
for
just
the
criterion
allocation of treatment.
Nozick (1974: 234) criticisesthe first premiseof this argumentand suggestsmedical
is
need not the only proper criterion for the distribution of health careresources.He
is
for
he
barbering
if
that
there
this
no support
argumentand asks
shouldbe
claims
distributed accordingto barberingneed,rather than the wishesof the barberhimself
The barber may, for example,only wish to cut the hair of those who give very
internal
In
be
he
the
to
tips
and should allowed act accordingly. other words,
generous
the
take
the
person'sparticular
over
necessarily
precedence
not
activity
should
goal of
Nozick
his
libertarian
From
for
the
perspective,
activity.
reasons carrying out
be
they
doctors
their
to
wish and
as
that
services
able
allocate
should
emphasizes
This
approachwould clearly
accordingto their own professionaland personalvalues.
be incompatiblewith a state operatedNHS where feesand salariesare establishedand
by
controlled the government.
free
laws
that
the
of a
Libertarians, such as Hayek andNozick, are primarily concerned
their
in
their
and
individuals
to
the
purposes
of
own
pursuit
act
enable
should
society
the
Any
it.
to
of
pattern
a
particular
attempt secure
own good as they perceive
based
it
is
(whether
individuals
on
within society
distribution of goods and servicesto
the public authorities'
Libertarians
desire)
is
opposed.
perception of needs,merit or
because
framework
the
the
of
or
results
outcomes
with
are not generally concerned
67
they argue that the outcomeswhich result from individuals pursuingtheir
own
conception of the good will be just, provided there is respectfor the freedom of others.
In other words the free market is inherentlyjust. An injustice
if
individuals
occurs
are coerced and unableto make use of opportunities, asthey would wish.
Libertarians reject the idea that we are under any obligation to rectify unequal
circumstances.,
unlessmaybewe have createdit by force of fraud. Whenthis theory of
distributive justice is appliedto the provision of health carethere are potential
problems. Many people, who are not libertarians,will intuitively feel that it is not just
to allow the naturally disadvantagedto experienceill health,pain or suffering,with no
for
be
denied
health
born
because
into
to
they
medical care, or
children
care
are
a poor
family.
There is also somethingcontradictory in this theory which suggeststhe ultimate value
is a commitmentto the principle of liberty and allowing peopleto maketheir own
determination),
(self
and yet acknowledgesno obligation to rectify those
choices,
individuals
III
to
the
make choices.
ability of
circumstanceswhich can undermine
health is obviously a factor, which naturally contributesto the loss of freedom;people
One
the
that
take
argue
to
n-fight
opportunities.
advantageof
are restricted and unable
health
is
health
to
for
and
generally
to
promote
care
system
a
provide
society
rationale
is
Health
freedom.
those
individual
of
one
thereby
time
promote
at the same
freedom
to
individuals
the
is
to
background conditions which vital to enable
achieve
live their lives as they choose, It shouldthereforebe treated as a specialcaseand not
free
the
the
market.
principles of
subjectto
the
libertarian
of
some
has
this
questioned
(198
and
8)
argument
Graham
examined
underlying
health
is
and
He
there
of
concept
single
uniform
no
concludes
assumptions.
it is therefore unlikely
is
health
for
the provision of
care a single
that the rationale
68
formula. He statesthat 'there is
still plenty of scopefor intelligible disagreementabout
the importance of health in relation to
other values' (Graham 1988: 115). It is not
therefore justified to assumethat all individuals will
health
value
more than other
goods. They should be free to decidefor themselvesif they wish to contributeto
health insurance,and whether they adopt healthylifestyle,
a
or take iisks, which might
contribute to future trauma or disease.
Graham(1988: 100) views health as a cluster of different
conditionsand suggeststhat
the health service should treat someconditions, which are life threateningand result in
pain and disability. However, health care also catersfor many lessromantic ailments
suchas acne,constipation or ingrown toenails, and a numberof conditions,which
from
lifestyles,
result
self-chosen
such as headacheswhich may be the result of a
hangoverrather than a life threateninganeurysm. If ill healthis viewed as a cluster of
different conditions, it follows that the rationalefor providing healthcarewill be
dependenton a variety of arguments. It is more difficult to justify the treatmentof
theselatter conditions on the NHS.
ALILccording
to Graham,health is a partly subjective,evaluativeconceptand it is not just
is
determined
in
by
health
an anatomicalor physiological concept:
part what mattersto
the individual, relative to his or her own goals and life expectations.He goeson to
but
it
for
is
health
that
must competeagainstother values
people
one value
suggest
in
beautiful
looking
taking
part
and
such as the pleasureof smoking, eating chocolate,
be
individual
to
libertarian
The
that
the
allowed
must
emphasizes
exciting sports.
hobbies
between
that
and
thesevalues and reality shows
peoplewill adopt
choose
lifestyles, which pose a significant risk to health.
health
libertarians,
that
the
Graham,like many other
concludes
provision of general
for
is
There
to
themselves.
left
to
be
private
no
objection
to
choose
people
care must
69
health insuranceschemesbecausethe individual
can chooseor declineto take part.
There is however no justification for a compulsory systemof health
careprovision for
(such
all citizens
as the NHS) financedout of compulsorytaxation. This involves
coercion, which cannot be justified evenif there are welfare benefitsfor some.
Sterba(1992) has presentedan argumentto justify the welfare statewithin a libertarian
framework. He suggeststhere is a conflict of liberties betweenthe rich andthe poor:
'In this conflict situation, the rich, of course,havemore than enoughresourcesto
basic
By
lack
their
the
the resourcesto meettheir most
satisfy
needs.
contrast,
poor
basic nutritional needseventhough they havetried all the meansavailableto them that
libertarians regard as legitimate for acquiring such resources' (Sterba 1992.56). In a
is
liberty
is
there
the
the
of
society where
no welfare state
poor at stake since they are
from
laws
take
the surplus
to
the
existing
governing property rights,
unable,within
basic
in
to
their
the
nutritional needs.
rich order meet
possessionsof
Sterbasuggeststhat we have a choicebetweenacceptingthat the rich shouldhavethe
liberty to use their surplusresourcesfor luxury purposes,or that the poor shouldhave
basic
their
from
to
liberty
they
nutritional needs.
the rich what
to take
the
require meet
For Libertarians the ultimate ideal is liberty and this choicerepresentsa conflict of
Sterba
liberty
the
liberties, and we must apparentlychooseone
other.
and reject
is
the
from
the
rich
liberty
of
to
take
the
resources
surplus
the
that
poor
of
concludes
to
be
it
to
a
because
make
people
expect
unreasonable
would
morally preferable,
in
their
starvation.
result
sacrifice,which could potentially
to
this
to
it
extend
While Sterba cites nutritional needs would seementirely appropriate
doubt
life.
I
to
normal
health
support
basic
necessary
are
which
needs
care
embrace
the
the
be
current
to
on
available
services
all
cover
extended
that the argument could
infertility
for
NHS such as cosmetic surgery, elective surgery varicoseveins, or
70
treatment and it is relevant that someof these serviceshave alreadybeen
withdrawn,
under recent local purchasingagreements.To take the extremeexample,it would
be
surely unreasonableto expectthe poor to sacrificelife savingmedicaltreatmentin
order to allow the rich membersof societyto maintainthe freedomto buy life
luxuries.
It would also seemunreasonableto expectpeopleto suffer pain
enhancing
and severephysical or psychologicaldiscomfort in order to preservethe liberty of
others to use their surplusresourcesto acquireluxuries.
Somelibertarianswould not agreewith the argumentspresentedby Sterba. Machan
(1992) claimsthere is no foundation for 'why the needs' of somepeoplemust be
lives
'
Machan
the
of
claims upon
others.
also suggeststhat genuine casesof the
helplesslypoor are indeedrare, and often the result of political oppression,ratherthan
it
for
help,
disaster
disease.
He
that
that
the
and
or
points out
poor shouldask
natural
for
if
it
involved
failed
help,
if
be
immoral
to
the rich
minimal sacrifice
offer
would then
is
basis
Charity
therefore
to
acceptable
them.
and
on
a
give
voluntary
people
allows
justice.
libertarian
to
the
approach
within
by
illness
their
have
if
to
their
choicesand
However,, people
or
poverty
contributed
behaviour,the rich may feel lessinclined to offer support. Sterba'sproposalseemsto
imply that the rich have a duty to help the poor, but this cannotbe regardlessof why
health
for
has
their
to
care,why should
need
they are poor. If someone contributed
help
have
them?
to
others
be
lifestyle
libertarian
from
a
relevant
would
point,
stand
The question of whether
a
Libertarians
health
limited
remains.
resources
care
to
allocate
criterion on which
to
freedom
have
their
to
and
the
good
own
choose
that
should
people
emphasize
be
ind'v'duals
follows
It
that
should
their
values
best
chosen
how
to
decide
promote
Medical
2
Chapter
in
discussed
been
has
need
71
allowed to behavein ways, which will be a risk to their health. Individuals are free to
choosetheir own lifestyle provided that it doesnot interfere with the freedomof
others: they can choosetheir own poisonsand risks!
Nozick (1974: ix) makesthis point in the introduction to his book: 'the statemay not
its
for
use coercive apparatus the purposeof getting somecitizensto aid others,or in
order to prohibit activities to people for their own good or protection.' In other
4
is
justified
paternalism
words,
not
and the state shouldremainneutral about what
constitutesthe good life. Libertarianswould not acceptcoercivemeasures,but they
distribution
information
health
the
should support
of
educationsincethis would
and
facilitate individuals to maketheir own choices. Indeed,libertariansmight arguethat
the state has a duty to provide relevant healthwarningsabout the risks of smokingand
information
based
decisions
individuals
diet,
that
rather
on accurate
can make
so
poor
than myth or advertisingcampaigns.
Graham,
by
described
Nozick
libertarian
based
and
In a society
principles,as
upon the
be
ill.
It
became
for
health
thosewho
would not
care
there would be no stateprovided
by
health
ill
their
had
individual
their
to
the
to
contributed
significant as whether
have
ill
their
became
to
resources
All
own
lifestyle.
on
rely
those
would
who
adopted
be
in
for
the
on
reliant
indirectly
treatment
or
place,
directly
market
medical
to pay
or
individuals.
charitableorganizationsor
health
to
care
In such a framework many people would contribute voluntarily
There
basis.
be
insuranceschemes,which would probably organizedon a commercial
lifestyle.
to
People
be
to
admit
who
is no doubt that premiums can adjustedaccording
5.6
Chapter
in
discussed
be
Patemalism wifl
72
horse riding, skiing, or smoking
be
can askedto pay a higher premiumfor the same
protection offered to people who adopt a so called healthylifestyle, or fail to
admit to
their bad habits! For those people who admit to smoking,higher
premiumsare already
a reality. Physical attributes, such as obesity,which are associatedwith a certain
lifestyle, can also be used to set a range of premiums. The libertarian
would not object
to this systembecauseindividuals would still maintainthe liberty to choose
whetherto
in
partake the systemor not. Sincewe may not be in agreementaboutwhich goods
are valuable, people should be allowed to determinetheir own priorities and values,
differences
justify
interferenceor coercion of others.
and any
will not
Libertarians are committed to the notion of value pluralism. There are many
lifestyles,
libertarians
While
and
worthwhile
valuable
goals, and relationships.
may
drug
taking and prostitution this doesnot meanthat they endorseor
allow smoking,
behaviour.
is
important
It
distinction
betweenallowing
to
the
welcome such
maintain
certain activities and condoning or praising suchactions. Hencethe libertarianmay
lifestyle,
but
permit smoking, overeatingand a sedentary
may not approveof such
behaviour. One can speculatethat somelibertariansmight not be sympatheticto those
individuals who had contributed to their ill healthby their chosenpursuits, and
instead
help,
decline
to
those
to
to
they
give
who
preferring
offer
consequently
might
likely
be
Libertarians
fault
to
ill,
their
through
are not
own.
of
no
apparently
were
individuals
hold
scepticalabout our ability to make voluntary choicesand may
'
less
judgemental
favour
Others
behaviour.
for
approach,
a
might
responsible their
the
help
of
causes
regardless
apparent,
suffering
were
offering
where medical need and
injury.
illness
or
of
5 Respecting liberty would hardly be attractive if people were unable to make choices for themselves
discussed
in
be
/
involuntary
Detern-iinism
choices
will
and
voluntary
puppets.
mere
as
and responded
chapter 4.
73
3.3
The socialist approach to justice.
The socialist account of justice doesnot acceptthe fundamentalfairnessof the market
and the associatedindividualistic approachto the distribution of goods. Ratherthe
socialist conception of justice takes equality to be the ultimate political ideal. Burdens
benefits
in
life
ideally
be
distributed
and
should
accordingto the principle: 'From each
his
to
according
ability, to eachaccordingto his needs' (Marx andEngels 1992: 85).
There are certain benefits, such as education,health and basichousing,which should
be distributed accordingto claims of need,rather than in terms of cashpayment,or any
in
ideas
Socialist
are reflected the welfare state
conception of social worth or merit.
(Plant
1991:
186).
the
the
claims of need
recognition of
and
There are though, inherentweaknessesin an approach,which distributesbenefits
in
in
distribution
the
both
in
the
and
to
society
general
goods
of
according needs,
(1992.93)
ONeill
the
Nell
health
statement
criticise
and
care resources.
allocation of
'From eachaccording to his ability, to eachaccordingto his need' on three counts.
Firstly, there is no guarantee,evenif all contribute accordingto their abilities,that all
be
there
their
to
if
a
may
Secondly,
be
abilities
according
contribute
all
met.
needswill
Why
is
incentive
Finally,
evident.
structure
no
met.
are
material surplus after all needs
in
jobs
to
hard,
order
unpleasant
at
some
to
particularly
work
want
people
should
in
benefit others? The principle gives no guidance situationsof scarcity,when some
is
there
of
surplus
in
a
when
of
abundance
needsmust go unmet, or situations
for
does
priorities
assigning
a
method
present
In
the
not
approach
resources. addition,
amongstneeds.
insisted
he
the
that
be
and
created
would
abundance
where
Marx visualized a society
6
One
in
can
abundance.
of
context
a
only
applicable
was
ofjustice
socialist principle
Principle
Socialist
in
the
that
(1992)
ONeill
Nell
are
agreement
and
as
Contemporary writers such
in the scenario of abundance
implemented
be
can only
74
6
insist
that needsshould be met when in practice they
only
canbe met. Nielson (1992:
105) statesthat his 'radical egalitarianprinciples are meantactuallyto guide
practice,
to directly determinewhat we are to do, only in a world of extensiveabundance.
1)
In the scenarioof health care provision, I have arguedthat there will alwaysbe
7
infinite
health
limited
financial
budget.
Rationing of
potentially
care needsanda
health care resourcesis therefore inevitable, aswe will be unableto meet all medical
needs. The socialist principle of justice doesnot presentany guidelineson how to
how
decisions
to
prioritize needsand
make
about which patient shouldbe chosenfor
treatment, when it is impossibleto treat everyone. Additional principleswould be
differentiate
between
to
needed
patients.
There is an additional weaknessin any framework, which suggeststhat resources
in
discussed
2,
As
be
distributed
the
to
scopeof
chapter
need.
according
should
8
breast
determine.
Does
is
difficult
to
reduction
cosmetic surgery or
medical need
be
Such
treatments
may undoubtedly of enormoussignificance
meet a medical need?
for the individual, and can obviously contribute to psychologicalwell-being. Indeed,
drastic
drive
to
take
infertility
treatment
a person
can
or
refusal of cosmetic surgery
stepsand possibly evento suicide.
health
justice
the
care
allocationof
suggeststhat
in summary,the socialist approachto
Indeed
individual.
the
the
be
the
to
of
needs
medical
according
provision should
the
be
to
on
one
ideal
every
based
that
available
is
should
the
NHS
services
on
current
In
delivery.
there
free
are already
reality,,
the
basisof clinical need and
point of
at
dental
including
NHS,
the
in
current
on
the
of
services
provision
certain exceptions
longer
available
widely
are
no
which
surgery,
infertility
cosmetic
treatment,
and
care,
difficult
therefore
We
needs
and
medical
NHSall
meet
cannot
the
to everyoneon
1.4
in
takes
chapter
place
inevitability
rationing
of
the
discussion
on
Further
2.2
in
takes
chapter
place
Further discussion on needs
75
decisionswill have to be
made about which patientsare treated, and which patientsare
not treated or kept waiting.
Is lifestyle a relevant criterion on which to
allocateresources?From the socialist
standpointthere is no obvious answer. In an ideal stateof abundance,,
all patientswho
need care could be treated, regardlessof their lifestyle, If you allocateresources
strictly according to need,the causeof needis surelyirrelevant and so it would not be
significant as to whether the condition was self-inflicted or not,
In the current situation of limited resources,the socialistprinciple doesnot help us to
determinewhether it would be fair to discriminateon the basisof lifestyle. However,
Nell and ONeill (1992: 97) recognizethat for certain questionsabout distributive
justice, one might needto invoke a supplementaryprinciple of distribution, which
have
be
justified by separateand non-arbitraryarguments. This permitsthe
to
would
including
lifestyle, might be
notion of an eclectic approachwhere a variety of criteria,
for
determine
be
It
treatment.
to
might,
example, appropriate
who should receive
used
to delay treatment for those who are recklessand have contributedto their illnessor
injury, sincethey will contribute to the increasingneedfor health care. If desertwere
taken into account, it might help curb recklessand foolish behaviourand so reducethe
demandson the health service.
76
3.4
Justice according to Rawls
In this section, I will presenta brief outline of the theory
ofjustice as presentedby
Rawls, and discussthe implications for the allocation health
of
careresources. I will
explore whether this theory will provide any guidancefor the centralquestionof this
dissertation:is it fair to ration health care resourcespartly accordingto
previous
lifestyle?
Rawls (1972) presentsa comprehensivepolitical theory, which structuresour different
intuitions according to three specified principles. 9 The first principle ofjustice, the
'Ideal of Liberty' states 'Each person is to have an equal right to the most extensive
total system of equal basic liberties compatible with a similar system of liberty for all'
(Rawls 1972: 250). According to this principle, the government or authorities should
behaviour,
(including
health-related
to
the
not adopt coercive measures change
behaviour), of individuals, if suchmeasuresconflict with the free choicesof
individuals. According to Rawls, individualshave priorities and valuesandwill
developtheir own life plan with someidea of what they would like to be or what they
individuals
liberty
like
The
their
to
to
pursue
of
allow
principle
will
would
achieve.
own chosengoals.
The secondprinciple proposedby Rawls is known asthe 'Difference Principle' and in
in
for
ideal
it
all citizens,except certain specific
of equality
essence, advocatesthe
be
inequalities
'Social
to
The
that
are
and economic
principle states
circumstances.
'
Rawls
least
benefit
the
the
to
advantaged...
of
greatest
arrangedso that they are ...
in
differences
be
the ownership
there
(1972: 302). Rawls acceptsthat
may considerable
justified
be
distribution
in
providing
only
can
unequal
society.;
any
of various goods
least
benefit
the
the
to
well off.
of
greater
that the disparities of wealth contribute
9 Rawls proposes two principles, but the secondprinciple is subdivided into two, so I will exalnine the
another
one
with
their
relationship
three principles and
77
Hence social and economic inequalities justified if,
are
and only if, they work to the
advantageof the most disadvantagedin society. (Just how
you identify who is the
least well off is controversial).
The third principle is closely related to the difference
principle and is known as the
'Principle of Fair Equality of Opportunity'. It
statesthat 'social and economic
inequalitiesare to be arrangedso that they
are attachedto offices and positionsopen
to all under conditions of fair equality of opportunity' (Rawls 1972: 302). This
principle suggeststhat it is morally acceptableto have different rewardsfor different
jobs and positions, provided that the competition for
securingthose positionsis fair.
Fairnessrequiresthat jobs should be allocatedaccordingto relevantdifferences
betweenindividuals, such as their qualificationsand capacityto do the job.
Differences such as sexýrace, and ethnic backgroundare not relevantcriteria in the
selectionprocessfor most jobs.
Any theory, which proposes a variety of principles, can potentially result in internal
conflict. Rawls therefore imposes a system of priority amongst the OF,erent elementsin
his theory and proposes that the first principle of equal basic liberty must always take
precedence; 'Liberty can be restricted only for the sake of liberty' (Rawls 1972: 302).
In addition, the principle of fair equality of opportunity must take priority over the
principle of equality of resources.
Rawls claims that theseprinciples canbe justified by their correspondencewith those
judgement.
He
also claims
principles, which we would chooseafter consideredmoral
in
that rational people, who are placed the 'original position' of an imaginarysociety,
in
to
their
ofjustice
principles
order
maxin-fise
shareof
certain
choose
naturally
would
ignorant
People,
their
the
are
about
own
conception
of
good and
who
primary goods.
behind
'veil
ignorance,
'
the
talents,
of
will, accordingto
their own skills and natural
78
Rawls, naturally choosethese
principles. Peoplewould be concernedto protect their
freedom of choice so that they
be
would
able to pursuetheir own conceptionsof the
good; hencethe first principle of liberty. In addition, Rawls claims,peoplewho
were
ignorant of their own position in the distribution
of social and econon-ficadvantages
would ensurethat the worst position was as good as possible. Peoplewould therefore
choosea principle of equality, except in circumstanceswhere inequalitywould benefit
those in the most disadvantagedpositions.
The 'veil of ignorance' is an intuitive test of fairnesssinceit preventspeoplefrom
promoting their own perception of the good or establishinga framework which will
advantagetheir particular position, social circumstancesor natural abilities. This
approachto justice is modeledon the intuitive approachto justice and fairnesswhich is
often adoptedwith children: the one who cuts the cake doesnot know which piecehe
he
fairly
that
the
will receive, so
cuts
cake as
as possible.
Rawls suggeststhat it is possibleto identify a set of primary goods, which represent
those things that a rational man would want regardlessof his own life plan and goals.
In a pluralist society, one can assumethat people's life planswin differ and could
'Regardless
(1972:
Rawls
92)
Nevertheless,
states:
of what an
potentially conflict.
individual's rational plans are in detail, it is assumedthat there are variousthings which
he would prefer more of rather than less.' Primary socialgoods are thosegoods,
liberties,
include
institutions,
by
distributed
powers and
rights and
and
social
which are
(Rawls
1972.62).
income
and wealth, and a senseof one'sown worth
opportunities,
in
health
themselves.
does
Rawls
as
social
goods
primary
and
education
not recognize
in
'natural
be
health
Rather he proposesthat
good' association
should categorizedas a
by
is
directly
it
because
imagination,
the
intelligence
controlled
not
and
with vigour,
These
62).
1972:
(Rawls
natural primary goods are affected
basic structure of society
distributed
by
directly
them.
but
by social institutions
are not
79
While it is certainly the casethat no amount of health care provision, or any structure
of society, can guaranteehealth as such,medicalresourcescan determinethe
opportunities that an individual can hope to expect. For somepeoplewho are
dependenton medical care and drugs, it makeslittle senseto discussliberty and
if
lifesaving
treatment is not available. For thosewho require expensive
opportunities
health
distribution
be
the
ongoing
care,
of
and
and
power will not significant,
wealth
lifesaving
is
I
treatment
their
available.
proposethat a rational manmight
unless
therefore wish to include lifesaving health care as one of the primary goods.
I have presenteda brief summaryof Rawls'stheory ofjustice. I will now considerthe
implications of this theory for the distribution of health careresources. There aretwo
key questions,which I wish to explore:
(i
Should health care be traded in the market place like other commodities?
be
health
justice
to
distributive
carewould
( ii Which principles of
regardingaccess
in
individuals
by
the
original position?
chosen rational
does
he
in
income
not
societyand
Rawls focuseson the distribution of wealth and
Rawls
Rather
individuals.
between
health
issue
discuss
care
the
allocating
of
explicitly
'that
difficult
all
(1982: 168) statesthat he hasput this
problem asideand assumed
He
'
range.
normal
a
certain
have
within
capacities
physical and psychological
citizens
fundamental
by
the
problem ofjustice concerns
that
justifies this approach suggesting
if
in
that
a
and
full
society'
and active participants
'the relations amongthose who are
(Rawls
later
handle
the
cases
other
for
can
the
is
we
range,
normal
theory established
1993: 272).
his
line
in
distributed,
fairly
income
with
if
are
Rawls seemsto assumethat wealth and
In
distributed.
this
fairly
be
will
follows
that
it
commodities
other
three principles,
and
is
computers
as
such
goods,
many
one
of
as
seen
health
provision
care
system,
80
cars, which individuals can purchaseif they wish within the market place. In addition,
individuals could chooseto protect themselvesagainstfuture
costs of accidentsand ill
health, by contributing to voluntary insuranceschemesat a level
determine
they
which
accordingto their own preferencesand in relation to their own financial situation.
It is pertinent to ask whether health care shouldbe viewed in the sameway as other
buy
in
to
commodities,which we agree
and sell a market place. Or is healthcare
it
be
differentiated
from other goods? While recognizingthat
that
special so
should
health care is obviously a broad and diversenotion, incorporatingvarious institutions
health
I
that
and services, suggest
care generallymeetsa basicneedfor humanbeings.
Health care is important and different from other goods becauseit promotesand
functioning
is
future
fundamental
to
the
preservesnormal
and
opportunitiesof each
individual. If people are deniedaccessto health carethey may not havethe same
chancesasthose who are given medical care.
Norman Daniels (1985) presents this argument in his discussion concerning the
is
health
He
health
that
careprovision a
suggests
care resources.
macroallocationof
distributed
be
than
to
wealth,
need
rather
according
specialgood, which should
becauseit is fundamentalto the provision of equality of opportunity. 'Impairment of
individual's
disability
disease
functioning
opportunity
through
an
restricts
and
normal
have
his
talents
made
the
would
and
skills
that
to
range
normal
of
portion
relative
health
33).
In
(Daniels
1985:
healthy'
this
he
should
him
care
way,
to
were
available
lives,
lead
for
to
is
normal
be comparedwith education,which also necessary people
is
is
health
This
a
not
that
and
special,
have
care
view
a range of opportunities.
and
in
is
the
in
be
the
reflected
place,
market
solely
purchased
should
which
commodity,
NHS ideology.
does
health
the
primary socialgoods and
care among
While Rawls does not include
81
distinguish
it from other commodities,I would agreewith Danielsthat health care
not
provision should be included within those social organizations,which help to promote
fair equality of opportunity. Health care provision shouldthereforebe consideredas a
specialgood and it should be distributed accordingto needrather than the ability to
pay.
My secondquestion is which principles of distributivejustice, regardingaccessto
health care, would the rational personin the original position choose? Even if the veil
fair,
it
is
ignorance
is
device
for
determining
still
acceptedas a
of
what principlesare
individual
be
Rawls
that
the
rational
chosen.
suggests
not clear which principles would
be
Why
difference
but
the
the
this
should
challenged.
principle,
can
would choose
in
defines
terms
individual
the
of
off
primarily
worst
choosea principle, which
rational
income and wealth and makesno direct referenceto people'snatural goods suchas
intelligence,health or physical ability? According to Rawls, peoplecanbe equallywell
'primary
have
the
that
they
socialgoods' and yet one person
same
off provided only
ill-health.
from
handicapped,
be
or suffering
may physically or mentally
life
in
to
being
determine
health
and opportunities
I suggestthat
our overall well
could
is
health
If
that
accept
we
than
wealth.
economic
our
extent
an equivalentor greater
in
individual
the original position might
fundamentalto humanwelfare, the rational
For
health
importance
example,
care.
the
of
reflected
to
which
principles,
choose
wish
financial
of
to
health
regardless
and
distributed
need
according
care
a principle that
to
individual
choose
wish
Similarly,
might
the
be
rational
chosen.
might
assets
is
by
that
It
for
certain
means
no
people.
all
young
principles, which ensurededucation
in
difference
the
principle
in
choose
the
original position would
the rational individual
preferenceto other principles.
they
that
individuals
normally
would
assume
might
From behind the veil of ignorance.,
82
be independentand able to managetheir
in
own affairs society. Hencethey opt for a
framework which promotes individual freedom
and choice. In the.hypothetical
it
is
contract,
also probable that individuals would agreeto certainprotective measures
for those individuals who were unableto make rational decisions
and protect their own
interests. For example,individuals who are immature,experiencelearningdifficulties,
or are affected by seriousmental disease,shouldbe protected againsttheir own
potentially irrational inclinations or weakness. The individual in the original position
might acceptpaternalismin somecasesso that others could act to overrideimmediate
irrational wishes of individuals in order to promote their best interests.
Rawls (1972: 249) suggeststhat paternalisticinterventionsshouldbe guidedby 'the
individuals own settled preferencesand interestsinsofar asthey are not irrational, or
failing a knowledge of these,by the theory of primary goods'. He proposesthat we
be
if
individual
his
he
that
the
recovers
powers
or when
rational
would
should satisfied
is
his
future-orientated
decisions
behalf
This
the
consent not
accept
made on
individual
is
behaving
be
in
because
itself
that
the
there
must also evidence
sufficient
irrationally or with weakness of will. Since Rawls gives lexical priority to the first
it
follows
individuals
that
liberty,
their
to
choices,
own
make
principle of
which enables
longer
is
individual
be
justified
to
interventions
the
able
no
when
will only
paternalistic
'O
decisions.
make rational
I concludethat the rational individual in the original position might agreeto certain
legislation,
the
include
These
interventions.
enforces
which
current
might
paternalistic
for
the
helmets,
belts
smoking
and
and restricts alcohol
and motorbike
use of car seat
individual
irrational
the
the
of
wishes
Such
short-term
overcome
will
measures
young.
In
lapse
people
would
most
mind
state
of
a
rational
indeed
memory!
of
temporary
a
or
know
difficult
is
It
the
liberty.
to
whether
their
more
accept such restrictions of
be
it
In
decisions,
this
to.
would
case,
10All individual who is able to make rational
may choosenot
best
interests.
in
their
to
justifiable for doctors, or others, act
83
individual
rational
would agreeto moreintrusiverestrictionsin orderto protectthem
from their own recklessness,
Finally, I will explore whether Rawls'stheory
ofjustice will help us to answerthe
central question of this dissertation:is it fair to ration health careresourcesaccording
to previous lifestyle? SinceRawls'stheory doesnot attempt to
give specificguidelines
for the allocation of health care provision betweenindividualsthere is
no obvious
here.
However, the theory doesnot explicitly suggestthat it
answer
be
would unfair
to discriminateagainstthose who had voluntarily contributedto their own ill health.
Rawls (1972: 96) statesthat the primary subjectofjustice is the basic structure
of
society becauseits effects are so profound and pervasiveand presentfrom birth. His
theory ofjustice focuseson the ways in which the major socialinstitutions might
regulatethe inequalities,which affect people'slife-prospects(Rawls 1972: 7).
However Rawls suggeststhat once his principles are satisfied'other inequalitiesare
from
to
allowed arise
men'svoluntary actions' (Rawls 1972: 96). So it appearsthat
the inequalitieswhich arisefrom people'svoluntary choicesare the individual'sown
responsibility. For example,when inequalitiesof income are the result of choices,
hard
leisure,
individual
been
has
to
to
time
the
either work
on
or spendextra
not
treated unfairly.
Rawls proposesthat inequalitiesof birth and natural endowmentare undeserved;
(nobody deservesto suffer from a hereditarycondition suchas haemophilia,cystic
fibrosis or low intelligence) and that theseinequalitiesshouldsomehowbe
fewer
help
for.
In
to
those
natural
with
essence,society must give more
compensated
(Rawls
According
1972:
100).
to
of
opportunity
to
equality
assets provide genuine
have
justified
those
to
to
is
it
Rawls
therefore
allocatemore resources
childrenwho
learning Miculties or health problems.
84
It is pertinent to the central question this dissertation
of
that Rawls suggests
'undeserved' inequalities should be
redressedto promote equality. This seemsto
imply that the individual can create
a situation where he or shedeservesdifferent
treatment. It follows that peoplewho needliver transplants
as a result of excessive
drinking may not comparefavourably to those
patientswho developscarcinomaof the
liver through no apparentfault. "
How would the rational individual, in the original position,
chooseto distributelimited
health care resources? The rational individual
have
to decidewhetherpeople
would
were responsiblefor their health-relatedbehaviour. Rawls promotesthe principle of
liberty and the ideal that people shouldbe ableto determinetheir
own priorities. In so
doing, he seemsto assumethat people can make choicesfor themselves.It follows
that if individuals have voluntarily chosento continueto smoke,overeator drink
excessivealcohol, with the knowledge of the risks to their health,then they ought to
acceptthe consequencesof their behaviour. It would thereforebe fair to give priority
to those people, who have maintaineda healthylifestyle, when it is impossibleto treat
everyone.
In addition, a systemwhich allowed open accessto health care for all, includingthe socalled 'undeserving' would not favour the prudent individual, who choosesto lead a
healthy lifestyle, and resiststhe temptation of sloth and overeating.Indeed,prudent
individuals who becomeill through no fault of their own, might find that the lin-fited
11
'undeserving
been
had
the
to
given
resources
already
.
However, the rational individual might have somereservationsabout whether people
lifestyle.
If
their
people are unableto control their
really can make choicesabout
Further discussion on this topic lAill take place in Chapter 7
85
lifestyle and health related behaviour,then it is
reasonableto choosea systemwhereby
has
everyone
accessto health care, irrespectively of whether they havemaintaineda
healthy lifestyle or not.
In his theory of justice, Rawls doesnot discussthe issueof individual
responsibilityfor
health related behaviour. Daniels (1996: 198) also acknowledgesthat his
own account
distributive
justice
in
health is incomplete,becausehe hasconcentratedon social
of
obligations to maintain and restore health and yet hasignored individual responsibility
to do so. He statesthat there is nothing in his approachthat is incompatiblewith
healthy
lifestyle
but that hard questionsstill remain
to
encouragingpeople adopt a
about 'how to distribute the burdensthat result when people"voluntarily" incur extra
health
the
risk and swell
costs of
care by doing so' (Daniels 1996: 198).
In summary,accordingto Rawls, individuals in the original position will choosethose
best
the
possibleaccessto the primary socialgoods,which
principles, which ensure
health
include
life.
does
lead
Rawls
them
to
careas a
not
a worthwhile
will enable
future
health
is
fundamental
but
have
I
to
that
proposed
primary social good,
is
income
It
therefore
to
to
possible
and
wealth.
comparable
opportunities, an extent
best
the
individuals
those
that rational
principles,which gave everyone,
might choose
for
individuals
Rawls
health
are responsible
suggeststhat
care.
possibleaccessto
inequalitiesthat arise from their own voluntary choices. This leavesus with a relevant
behaviour?
health-related
their
individuals
Do
make voluntary choicesabout
question:
86
3.5
The Communitarian approach to justice
Contemporary writers such as Alasdair MacIntyre, NfichaelWalzer andNfichaelSandel
presentan approachto justice, which recognizesthe claimsof citizenshipandthe
community as a whole, They criticize the image of an independentandlone individual
irrespective
who makeschoices
of his or her roles and commitmentsin life. Rather,
the communitarianapproachto justice views individuals aspart of the wider
in
life.
The communitarianchallengesthe
community and participants a common
have
individual
that
rights should always
priority and suggeststhat sometimes
notion
they can be overridden, or limited, by appealsto the good of the communityas a
whole.
Various authors such as Bell (1993), Allen Buchanan (1989) and Amy Gutmann
(1985) begin their account of communitarianism by assessingthe liberal political
liberalism
(1993:
4-8)
Bell
that
make
of
critics
communitarian
suggests
philosophy.
three generalclaims:
1. Liberalism rests on an overly individualistic conceptionof the self,
importance
social
insufficiently
the
or
to
Liberals
of
community
2.
sensitive
are
context;
the
does
least
adverse
recognise,
to,
Liberalism
not
sufficiently
3.
at
or
contributes
liberal
'atomistic
societies.
tendencies'
modem
of
the
to
effects related
I will examineeachclaim.in turn and presentthe alternativecommunitarianapproach.
but
liberalism,
the
limitations
literature
in
the
debate
of
the
about
There is considerable
for
implications
ideas,
the
and
developmentand clarification of the communitarian
ideas
tentative
I
about
therefore
some
present
will
explicit.
made
rarely
are
practice,
health
distribution
for
the
resources.
care
of
the implications of communitarianism.
kind
in
individuals
their
abstract
of
some
values
choose
implies
that
Liberal theory
87
detachedway and that individuals
determine
their own personaldestiny.
can
A,.
Alasdair
to
MacIntyre
this perception of the self is mistakenbecause
According
everyoneis born with a past and eachpersonhas a particular historical
and social
identity within the wider community. 'The
has
to find its moral identity in and
self
through its membershipin communitiessuch asthose of the family, the
neighbourhood,the city and the tribe' (MacIntyre 1984: 21). Even thoseindividuals
who rebel againsttheir identity are clearly affectedby their past and current roles.
Hence the self is 'embedded' in and at leastpartly constitutedby the traditions,
commitmentsand values of the community within which the personfinds him or
herself
Liberals, such as Rawls,,defendthe notion of individual rights and suggestthat the
individual should be free to standback and assessthe availableoptions and make
independentchoices;in this way the self is saidto be prior to its ends. It follows from
this vision of 'the self that the state should establisha neutral framework where
individuals can chooseamong competingpurposesand goalsto meettheir own life
plans. Individuals should not be penalisedfor different approachesto life. For
be
example,unorthodox religious or sexualpracticesshould permitted,provided that
they do not impinge of the liberty of others. The state shouldnot thereforeimposea
individuals
but
life,
the
are
particular vision of
promote an environmentwhere
good
free to persuetheir own perceptionsof the good.
Communitariancritics of rights-basedliberalismarguethat liberals exaggerateour
limit
for
the
social commitments,which will
self-determinationand neglect
capacity
Sandel
(1982:
179)
independent
that
for
argues
we are not
choice.
our capacity
independentbecausewe have allegiancesand loyalties, which contribute to the
family
'to
He
that
or communityor
attachments
writes
particular personswe are.
nation or people .....
justice
I
to
than
that
owe
more
requiresor even
some
allow
88
permits, not by reasonof agreementsI have madebut insteadin virtue those
of
more
or less enduring attachmentsand commitmentswhich taken together partly definethe
person I am' (Sandel 1982: 179).
The secondareaof concernfor the communitariancritics liberalismlies in
the
of
importance of the,social context of behaviour. Alasdair MacIntyre (1984: 208)
suggestswe cannot characterisebehaviour 'independentlyof intentions,beliefsand
settings.' Considerthe example,presentedby MacIntyre (1984.206), of the man
digging in the garden;this may fulfil a variety of different functions including
gardening,taking exercise,preparing for winter, or pleasingthe wife. While someof
theseanswerscharacterisethe agent's intentions, others are unintendedconsequences
of the actions. We can only identify and understandwhat someoueis doing when we
behaviour
in the context of the narrative history andthe settingin which it
the
place
occurs.
The notion that people are part of a wider communityand that their behaviourwill
has
interesting
implications
traditions
that
the
of
community
when
reflect
values and
behaviour.
health
According
to the communitarianapproach,the
to
applied
related
individual does not make decisionsabout healthrelatedbehaviourin isolation. The act
be
intention
but
drink
desire
the
to
could also
alcohol
of going to the pub may reflect a
This
in
the
to quencha thirst, socialisewith mates,act a manly way, or escape wife!
is
by
MacIntyre
illustrates
that
the
everyone under certain
point made
example
in
find
design
did
ourselves particular roles
not
and we
constraints;we enter a stagewe
if
blameworthy
individuals
be
We
as
should wary ofjudging
within an ongoing story.
find
in
by
determined
they
the
traditions
which
culture and
their behaviour is partially
themselves.
in
is
liberalism
by
reflected the
The third claim made communitariancritics of
89
statementmadeby Bell (1993: 7); 'There is undoubtedlya worrying trend in
c-entemorarv societiestowards a callous individualismthat wynorescommunitvand
social obligations.' This is evident in the breakdown of family ties and communal
commitmentsthroughout the Western societytodav.
Communitarians, as interpreted by Buchanan (1989: 856), emphasisethat a genuine
is
individuals.
Members
not
a
mere
association
of a communityshare
community
of
interests
is
interdependent.
It
their
are
claimedthat the
common goals and values, and
for
beings
benefit
from
fundamental
human
is
they
their
good
and
will
community a
'men
(1983:
Walzer
65)
Michael
that
and women cometogether
claims
membership.
becausethey literally can-notlive apart' and they needeachother for the communal
itself,
But
the
they
than
this
community
need
more
provision of security and welfare.
in
65)
(Walzer
1883:
to
'culture,
its
order
politics'
religion and
associated
with
life.
for
the
common
recognizeand agreeon what goods are necessary
be
because
from
differ
there
will
Walzer emphasizesthat communitieswill
eachother,
The
different
communitywill
different experiencesand
environmentalchallenges.
its
identify
for
own
determineits own patterns of provision
security and welfare and
be
for
the
embodied
will
Views
community
a
good
about what constitutes
priorities.
do
the
Communitarians
notion
accept
not
life
in the ways of
that
particular society.
of
the
framework,
common
supports
which
that
a political
of the neutral state, and argue
it.
by
replace
should
the
a
whole,
as
community
good as perceived
health
the
different
of
find
provision
to
governing
policies
One would therefore expect
care
to
based
initially
the
in
Britain
aspiration
on
was
in different societies. The NHS
basis
ability
of
the
regardless
need,
'every
of
clinical
on
health
to
citizen,
care
provide
in
USA
the
a
In
4).
reflects
1992:
Health
provision
contrast,
to pay' (Department of
'individuals
(1983:
89)
that
Walzer
in
claims
and
care
medical
free
enterprise
systemof
90
be
for
in
cared
will
proportion to their ability to pay and not to their needfor care'.
The so-called safety net and communalprovision is madeavailablefor the
very sick
but
level
lead
and old,
to inappropriateand inconsistentcare.
at a
where poverty can
According to the communitarianview, membersof the community shouldcometo an
agreementto redistribute the availableresourcesbasedon a sharedunderstandingof
their needs. People'ssenseof what they needwill reflect the valuesof the societyand
the prevailing culture and knowledge of the time. In essence,communitariansexpress
a commitmentto collective values and the promotion of the overall good of the whole
liberty
libertarian
ideal
If
then
the
the
principle of
community. a community values
they may not agreewith blanket public health provision, but prefer to allow individuals
to determinetheir own priorities.
Having discussedthe main communitarianideas,I will examinethe implicationsof
Many
health
distribution
the
to
resources.
care
of
adopting a communitarianapproach
implications
discuss
do
their
the
of
the
not
so-calledcommunitarianwriters
of
(1992
245)
MacIntyre
However,
-.
approach to the allocation of medical resources.
is
States
in
United
there
that
a
distribution
the
claiming
the
of
resources
criticizes
In
deprivation.
from
infant
horrifying level of
continued
mortality, which results
for
inappropriate
the
is
where
elderly
he
care
there
of
evidence
addition, claims
human
length
the
'the
directed
of
increasingly
to
of
extension
mindless
resourcesare
246).
1992:
(MacIntyre
life by medical scienceinto a more and more mindlessold age'
in
distribution
of generalgoods society,
In attempting to addressquestionsabout the
Michael Walzer (1983: 84) defendsthree principles:
its
they
the
to
as
members
of
needs
'that every political community must attend
those
needs;
collectively understand
in
be
distributed
to
distributed
need;
proportion
must
that the goods that are
91
and that the distribution must recogniseand uphold the underlying equality of
membership.'
While Walzer suggeststhat theseprinciples are relevantto the entire sphereof
welfare
and security, there are someproblemswhen they are appliedto the realm of health
fundamental
The
ideals
NHS
in
Britain recognizethat resourcesshouldbe
the
care.
of
allocatedaccordingto medical needand that all citizensof the communityare entitled
to certain health care, regardlessof ability to pay. On the face of it, this seemsto be
by
the
compatiblewith
principles as proposed Walzer. However there are still several
difficult questionsto answer. What preciselyis a medicalneedas understoodby the
is
British
the
membersof
community?
society madeup of a variety of different
have
different
be
priorities and may not ableto cometo a consensusas
cultures, which
to preciselywhich needsshouldbe treated. In a pluralist societythere will almost
be
Walzer
be
to
met
and
offers no
certainly conflict as which medicalneedsshould
decide
how
for
In
to
to
there
are no guidelinesas
addition,
mechanism arbitration.
be
which patient should offered treatmentwhen not all patients,with similar needs,can
be treated becauseof limited resources.
Secondly,who exactly are the membersof this society? Shouldmembershipinclude
in
babies,
those
who are a persistentvegetative
or
early embryos,very premature
At
certain
whether
question
could
the
mean,
one
and
callous
risk of appearing
state?
humanbeingsmight be excludedfrom 'membership'becauseof their medical
foreign
from
NHS
unless
countries,
In
the
people
exclude
may
addition,
condition.
financial
for
the
costs of treatment.
they are preparedto pay
helpful
by
Walzer
therefore
as appearson
as
The three principles as proposed
are not
distribution
the
of medicalresourcesremain.
initial examinationand questionsabout
In
ideas,
which could generateareasof priority.
There are however somegeneral
92
essence,I believe that the communitarianwould have to ask what type
of provision
and distribution of serviceswould benefit the community as a whole. I suggestthat the
emphasisfrom a communitarianperspectiveshould be towards public healthmeasures
to maintain and improve living and environmentalconditionsfor society
generally.
Initiatives which aimedto prevent pollution, maintain
a safeand appropriatefood
supply, and provide reasonablehousing for all the population shouldimprove the
health
general
and well being of all the membersof the community.
Such initiatives might involve coercion and could limit the freedomof certain
individuals but the overall good to the majority would override any supposedrights
of
the individual, accordingto the communitarian. Considerthe hygieneregulations
imposed
food
which are
on
producers;suchregulationscan force producersto adopt
certain standardsof hygiene,and potentially reduceprofit margins,in order to protect
the generalpublic and promote the good of the community as a whole.
The ancientAthenians,accordingto Walzer (1983: 67), provided public bathsand
in
free
for
the
to
gymnasiums
citizens preference social security or
medical services.
This presumably reflects the limited knowledge of medicine at that time. Nevertheless,
the gymnasiumsmay have encouragedindividualsto take regular exercisewith an
fitness
being.
One
improvement
in
their
could speculate
and
well
associated
general
that suchprovision today would also result in improved health andwould be a justified
if
funds,
their
that
the
overall
met
such
provision
agreed
community
use of available
beds
intensive
financial
to
The
care
resourcesallocated
vast amount of
welfare needs.
be
to
benefit
the
used
could
perhaps
community,
a
of
minority
only
or cots, which will
if
for
to
they
the
sports
allocated
community,
were
whole
provide a greater good
facilities.
be
health
Health education and
promotion programmes,which could shownto
93
improve the health of the community,
would also be a priority. The emphasison
maintaining health and preventing illnesswould be a good for the whole of societyfor
a variety of reasons. If membersof society remainhealthythey can contribute
positively to the overall good in terms of productivity at work, but also in sustaining
family bonds and commitments.12
It seemsreasonableto acceptthat early deathis usually a harm both to the individual
and the community, It is, therefore, relevantto ask whetherthe communitarianwould
restrict high-risk behaviour, such as smoking and parachutejumping, either by coercive
measuresor total prohibition of certain activities. While the liberal approachto justice
individuals
be
that
will emphasize
should free to choosetheir own behaviourin relation
to their own priorities and life plans,the communitarianapproachmight accept
collective strategiesto prevent early deathand accidents.
Of course,there are alreadycoercivemeasuresin the form of legal restrictionswhich
limit or prohibit certain behaviour: motorcyclists must wear helmets,car passengers
limited
belts
drivers
drink
The
can
amounts
of
alcohol.
and
only
must wear seat
because
legal
believe,
I
the
this
of
resulting
would
coercion
support
communitarian,
burdens
do
impose
Such
for
the
on
restrictions not
unbearable
community.
good
individuals and are generallywelcomedby membersof the community.
Collective strategiescould be extendedto control the production of alcohol and
Individuals
legally
the
to
public.
tobacco so that such substanceswere not
available
in
legally
the
have
they
to
associated
partook
therefore
as
whether
no choice
would
deaths.
in
be
the
number of premature
activities, and there might a reduction
However, these substancesare associatedwith pleasureand relaxation,and many
The
that
the
community
emphasize
would
the
communitarian
effects.
people enjoy
12Further discussion on health education will take place in chapter 5.2
94
should agreeon the common good and it seemsprobablethat membersof the
community would not currently agreeto a completeban on alcohol and smoking. In
banning
addition,
a pursuit may make it more attractive to the rebelliousand
be
ineffective
in practice.
prohibition may
The central question of this thesisis whether lifestyle would be a morally justifiable
criterion on which to allocatehealth care resources. The communitarianapproachto
justice doesnot presentan obvious answer. Coercivemeasures" (if neededand
litigation
to changethe health relatedbehaviourof individualscould be
effective) and
justified on the basisof a collective responseto promote the healthandwelfare of the
community. Rather than looking at argumentsfor and againstpaternalismandthe
interestsof individuals,,the communitarianwill considerthe commitments,
interdependenciesand sharedconcernfor the well being of the communityas a whole.
Communitariansmay feel justified in exerting pressureon membersof societyto
improve their health in order to promote the interestsof the communityas a whole.
They may also feel obliged to look after those individualswho fail to overcomebad
habits and subsequentlybecomeill and in needof care. It would be a strange
had
failed
to
those
to
medicalneeds,
memberswho
offer assistance
community,which
bad
luck.
from
these
so-calledself-infliction or
needsresulted
regardlessof whether
I concludethat the communitarianapproachto justice doesnot help us to answer
different
between
health
careresources
specific questionsabout the allocation of
individuals. It is however, relevant to note that the communitarianview doesnot
in
lifestyle
be
it
the
to
allocation
that
as
a
criterion
use
unjust
would
suggest
explicitly
health
of
care resources.
13Further discussion on coercion will take place in Chapter 5.4
95
3.6
Conclusions about distributive justice
and the allocation of health care
resources
I have describedfour different theories distributive justice
of
and examinedtheir
implications for the distribution of limited health
care resources. Eachtheory appeals
to different ultimate values and establishesits own set of
priorities. None of these
theories suggeststhat taking lifestyle into accountwhen allocating
scarcehealthcare
resourcesmust be unjust. In this conclusion,I will discusshow thesecontemporary
theories might help us to determinewhat would be fair or just in the distribution
of
scarcemedical resourcesbetweendifferent individuals.
Many of the liberal writers of today, such as Nozick (1974), Graham (1988)
and Rawls
(1972) emphasize the importance of a framework in society
which allows individuals
the freedom to pursue their own good, to an extent which does not infringe the
freedom of others. In this respect, liberalism does not make assumptions about
conceptions of the good life or what is valuable; rather it suggeststhat there are many
different worthwhile goals and relationships in life. Liberalism is thereýore committed
to the notion of moral pluralism and is basedon a principles,which will be neutral
betweendifferent conceptionsof the good.
Graham(1988.103) suggeststhat health is an 'evaluativeterm,' which embracesa
different
by
is
variety of
physiological and mental states,and perceivedandunderstood
individuals in different ways. For example,athletesand ballet dancersmay have
different expectations,priorities and goals concerningtheir healthfrom philosophers
health
fitness
He
the
conceptof
and proposes
compares
with
and ninety-year-olds.
that fitness is not an absolutephysiologicalcondition in itself, but rather a relative
for
is
different
from
is
fitness
Steve
for
Redgrave
is
fitness
the
What
term.
quite
what
levels
fitness
further
is
it
to
qualify
of
statement
with a
necessary
averageperson and
for
fitness
what.
about
96
If people have different values in life, there is
no reasonto supposethat they will
always wish to promote their health, rather than enjoying other competing
values,such
as the pleasureof horse riding, parachutejumping, sunbathingor over indulgencewith
excessivealcohol and good food. Theseactivities are often valued, and chosen,
despitethe known risks to health.
Liberals emphasizethat health is one value amongstmany others,
individuals
which
may chooseto pursue, and that society should allow peopleto maketheir own choices
behaviour.
Accordingly the stateis not justified in imposinga framework
their
about
health
for
of uniform
regimes all, or in coercingindividualsto forgo a particular
lifestyle which endangershealth. It follows that health careprofessionalsshould
usually allow people to make their own choicesabout health and refrain from imposing
their own conception of the good. It would seemthat doctors and nurseshavea duty
to inform people of the potential risks of their behaviour,so that peoplecan make
based
information.
choices
accurate
upon
The principle of respectfor individual liberty is relevantto the central questionof this
dissertation:Should individuals sometimesforfeit future health careif they knowingly
liberals,
individuals
behaviour?
According
to
to
should
choose adopt certain unhealthy
be allowed to adopt a lifestyle, which reflects their own valuesand priorities, provided
that this does not infiinge the liberty of others. Smoking,drugs and risky sports, such
decent
'any
(1992:
5)
Graham
3
that
boxing,
concludes
as
are therefore permitted.
legal systemmust allow the individual moral and religious freedom,andthis includes
the freedom for moral and religious error.'
in
lifestyle
that
they
if
individuals
However,
others
cannot assume
adopt an unhealthy
liberal
for
for
If
the
them
be
to
or pay
medical care.
care
prepared
society will
it
in
life,
freedom
to
their
the
justice
choose
priorities
own
people
to
allows
approach
97
follows that it would be wrong to
coercepeople into paying or supportinga uniform
health servicefor all. People might
voluntarily wish to give moneyor assistanceto
help those with medical needs,but a compulsory
systemof taxation would not be
justified. We might also speculatethat people
might be more willing to supportthose
become
ill
through no fault of their own, rather than those who had contributedto
who
their ill health or injury.
The secondidea to emergefrom this survey of four contemporaryapproachesto
distributive justice is the communitariannotion of the importanceof the community.
According to this view, individual rights, including the right to individual freedom,can
be overridden for the good of the community as a whole. This hasimportant
implications for the distribution of health careresources.
Considerthe treatment of infectious diseases:individualswho havenotifiable diseases.,
forfeit
tuberculosis,
the right to make certain choicesabout their treatmentand
suchas
be
forms
in
Similarly,
may also
of employment.
restricted
certain
surgeonswho
hepatitis
be
MV
B
the
contract
or
virus will not permittedto continueperforming
individuals
infectious
to
they
andthe
and a potential risk other
surgerywhile
remain
in
is
for
fteedom
Individual
the
the
community
sakeof
also restricted
community.
but
immunisation
Individuals
must
are not offered a choice,
programmes.
compulsory
For
in
diseases
travel.
to
order
provide evidenceof current vaccinationagainstcertain
being
before
allowed
example,a tourist n-fightneed evidenceof a choleravaccination
to travel to India. In eachcase.,the coercion is justified on the groundsof the good of
the wider community.
incidence
justice
to
the
to
of
The communitarianapproach
would seek reduce
in
It
the
that
the
death
community.
seems
probable
and morbidity
premature
be
for
the
health
as
a
perceived
the
of
community
would
members
promotion of
98
prionty and a generalgood. Health promotion and prevention of diseaseand accidents
would therefore be a priority. In addition, the communitarianmight encouragepeople
to adopt a healthy lifestyle and avoid known risks in order to reducethe financialcosts
of health care that the community will haveto bear, Finally, the communitymight
legal
to
agree
restrictions to limit certain high-risk behaviour,evenif this resultedin
the loss of individual freedom.
The liberal and the communitarianapproachesto justice appearto be in conflict with
eachother. Liberal theorists have soughtto developa framework, which
acknowledgesmoral pluralism and refrains from imposinga vision of the good upon
citizens. In contrast, the communitarianmight seekto minimizeill healthandthe
incidenceof premature deathin order to maintainthe commitmentsandrelationships,
balance
between
important
in
I
that
protecting
any community. suggest
a
which are so
between
promoting the commongood and welfare of the
private choice and
be
community as a whole should sought.
The distribution of health care resourcesis a complex and multifacetedprocessand it
is unlikely that any one principle alone shouldguide our actions. I concludethat
individual freedom should be permitted, but can bejustifiably overriddenfor the good
14
does
This
in
not provide a neat and
conclusion
of the community certain situations.
health
it
framework;
that
people
other
and
professionals,
care
means
rather
conclusive
have
health
distribution
decisions
faced
the
will
resources,
care
of
about
are
with
who
to considerboth individual freedom and the good of the community.
lifestyle
Is
thesis:
this
a morally relevant
Finally, I return to the central question of
I
this
that
of
review
conclude
resources?
to
medical
scarce
ration
criterion on which
be
it
justice
does
distributive
that
would
not suggest
four contemporary approaches to
liberty
B,
hepatitis
disease,
the
tuberculosis
infectious
14If an individual develops an
or
such as open
in
in
the
to
community.
be
protect
others
order
individual
restricted
may
of the
99
in
unfair or unjust, principle, to discriminateagainstthose individualswho adopt
lifestyles.
unhealthy
Further questionsshould be explored in order to determinewhat would be fair to
different individuals. For example:do people make informed and voluntary choices
for
health-related
behaviour?
lifestyles?
Are
their
their
people responsible
about
Shouldthey be blamed if they take risks and subsequentlyneedhealthcare? If so, who
is in an appropriateposition to makethis judgementfairly? Can a policy, which
discriminatesagainstindividuals who adopt unhealthylifestyles,be implementedin a
just and workable way?
100
ChapterFour
INDIVIDUAL
R-ESPONSEBILITY
4.1
Does determinismmake nonsenseof accountability?
4.2
Individual responsibility
4.3
Voluntary and Involuntary behaviour
4.4
Responsibility for our former selves
4.5
Unhealthybehaviour -justification and excuses
4.6
Should we blame people for their unhealthy lifestyle?
101
4.1
Does determinism make nonsense
of accountability?
Prior to any discussionabout individual responsibility and
whether we shouldblame
for
their former lifestyle, I wish to say somethingabout the notion of
people
determinismand free will. If determinismis accepted,
further
any
analysisof individual
1
be
fruitless.
Determinism,
described
by Honderich (1993: 6)
responsibilitymay
as
implies that somehowwe are not responsible;our choicesand decisions
free
are not
and what gives rise to them are merely causes,over which the individual hasno
control. Individuals change,or fail to change,their behaviourowing to what happens
to them or in them, but they are unableto chooseother than as they do, given their
history and circumstances.
However, if people do not have individual free-will, and could not have actedother
than asthey do, it surely makesa nonsenseof praisingthose peoplewho act in a good
blaming
do
do
fail
Yet,
those
to
way or conversely
offer praiseand
who
so.
we
blame
how
behave.
We
to
apportion
according
people
congratulatethe personwho
hasgiven up smoking or lost a stonein weight (not often the sameperson)andwe
blamedrunk drivers and hold them legally and morally responsiblefor their behaviour.
In addition, we feel guilty if we eat the extra creambun and may feel proud of
does
do
fact
if
The
this
that
the
temptation.
not show
we
ourselves we resist
determinismis mistaken,only that we do not seemto believein it.
The total elimination of voluntarinessfrom our understandingof humanbehaviour
has
(1993)
Machan
for
both
have
implications
applied ethics and public policy.
would
beings
human
in
is
free
can
arguedthat
will a necessitypresupposed applied ethics:
ftom
do
do,
their
previous events
actions not result solely
and
causesomeof what they
by
be
The
influenced
have
them.
factors,
range of options, which may chosen
or
which
' The debate about determinism and freewill has been discussedby Glover (1970), Honderich (1993),
Lucas (1993) Chapter 2, and Ayer 1982: 15-23 amongst many others.
102
individuals, is clearly limited by their particular
circumstances7
education,talents and
physical capacities,but even so they can make choices,from a varying numberof
options. Indeed, the assumptionthat people can make choicesis evidentin many
professionalcodes,which guide doctors, nurses,scientistsand othersto conduct
themselvesin certain ways and to abstainfrom various activities. Professionalsare
be
for
to
accountable their actions and praiseor blamewill be apportioned
seen
accordingto whether suchguidelinesare implemented.
Likewise, public policy, which attemptsto influencethe behaviourof people,would be
if
individuals
have
free
If
questionable
no
will.
people are simply unableto change
their behaviour, and have no power to originate choicesor decisions,we shouldreview
the processof health education. It would seemthat healthpromoters should
find
in
trying
to
the
concentrateon
change environmentalcircumstances which people
themselves,rather than focus on the individual. Somepeoplecertainlyfind it difficult
to changetheir behaviour: - "I just can't stop smoking!" Others certainly experience
do
but
breaking
habits,
in
difficulty
to
there
their
respond
others
many
who
are
great
information and an increasedunderstanding,persuasionand the offer of rewards,as
they successfullygive up smoking or other unhealthyhabits. In suchcaseswe offer
have
individuals
because
these
that
madea
we assume
praiseand congratulations,
behaviour.
in
their
choice and shown strong will power changing
Graham(1992-3 1) describescompatibilismasthe acceptanceof both freedomand
both
describing
in
is
is
as
action
an
there
to
contradictory
nothing
say
causality,which
free and caused. A choice is free if you are acting as you wish, and yet what you want
Free
have
factors
the
will
that
are.
be
you
person
made
you
the
result of external
may
bun,
I
if
I
desires,
the
to
that
eat
cream
behave
to
wish
so
our
to
according
allows us
later,
delay
the
treat
to
perhapsafter
until
eating
do so. Alternatively, I may choose
is
freedom
that
According
this
to
we
a
consciousness
view,
somestrenuousexercise.
103
are able to modify our behaviour and make deliberatechoices,which is reflectedin the
control that we sometimesfeel able to exert over our behaviour. Nevertheless,our
desiresmay be predeterminedand a result of externalcauses
and past experiences;they
be
not
are
static and may modified by praise or blame. In essence,the compatibilist
acceptsthat people are morally responsiblefor someof their actions,eventhough
factors, beyond their own control, may have determinedthe desiresof eachperson.2
It is beyond the scopeof this dissertationto expandon the complexdebateconcerning
determinismand whether it is compatiblewith the notion of free will. In the following
discussionabout individual responsibility,I will assumethat individualsdo havethe
decisions
if
limited
by
to
their
choices
originate
and
even
power
choicesare sometimes
the circumstancesin which they find themselves. This is reflectedin the praise,blame,
both
towards others and ourselves.
pride, and guilt, which we attribute
be
liberty
Hume's
is
may
understoodas
2 This accountof compatibilisn' consistentwith
view, where
be
One
desires.
in
liberty
can
to
is
it
if
with
one's
the
act
accordance
determinism,
compatiblewith
by
independent
influences
own
of
one's
themselves
desires
caused
if
the
are
free in this senseeven
Will.
104
4.2
Individual
responsibility
73-
'
government
documents
policy
and
consultative
ill
that
the
recognize
-Recent
causesof
health are complex, embracingsomefactors that the individual
cannotcontrol, suchas
the environment,genetic makeup,and aging. However, thesedocumentsemphasize
that lifestyle also has an important impact on health. Diet, physicalactivity, smoking,
behaviour
drugs
alcohol, sexual
and
are factors, which 'can have a dramaticand
influence
how
healthy
cumulative
on
people are and how long they will live'
(Departmentof Health 1998: 20). It hasbecomeincreasinglyapparentthat disease
illness
and
are not merely the result of bad luck or fate, but that in somecases
individuals may have contributed, by their choices,to the developmentof their own
poor health and associatedneedfor health care.
For example,individuals who chooseto jump out of a planewith a parachutefor
be
injured
charity may
on landing, and it would seemthat there is a clearrelationship
betweentheir chosenbehaviour and their subsequentinjury, Likewise, those
individualswho adopt an unhealthylifestyle, smoke,eat excessivelyand/ortake no
ill.
becoming
It
have
increased
that
therefore
their
appears
of
chances
exercise,
increasing
for
the risk of subsequent
people's actions are partly causally responsible
illness,,and their associated need for health care.
Nevertheless,people who adopt unhealthylifestyles and/or partakein dangeroussports
do not chooseor intend to becomeill or injured. Rather they hope that they will be the
lucky oneswho do not need subsequenthealth care. There is an elementof chance,or
luck, as to who will becomeill or injured. Walker (1997: 39) illustratesthis point with
is
distracted
intoxicated
surgeonwho unfortunate
or
the exampleof a negligent or
in
is
large
She
that
there
chance
injure
of
a
element
suggests
to
patient.
a
enough
3 SeeDepartment of Health (1998) Our Healthier Nation; Department of Health (1997) The New
NHS Modem and Dependable
105
meeting up with the precisecircumstanceswhich will lead to this dreadful outcome.
Indeed she observesthat severalother equally negligent,intoxicated or distracted
surgeonsmay be fortunate enoughto avoid harmingtheir patients.
In this chapter, I will examinea seriesof related questions. Firstly, assumingthat
by
do
habits,
lifestyle or sporting pursuits sometimescontributeto their
their
people
illness,is this aspectof their behaviour voluntary? Shouldwe be held responsiblefor
fonner
Can
behaviour
bejustifiable (not wrong) in
our
selves?
unhealthyor risky
individuals
Can
certain circumstances?
presentvarious excusesto explainwhy they
4
blamed
be
knowingly
Are
though
those people.,
they
took
risks?
even
shouldnot
in
blameworthy
health,
known
to
their
take
risks with
who voluntarily choose
if
is
it
be
If
they
appropriateto punishthese
punishedand so,
principle? yes, should
by
people, withholding treatment?
4 Austin( 1961) A pleafor excuses
106
4.3
Voluntary and Involuntary Behaviour.
If people adopt an unhealthylifestyle, is this behaviourvoluntary? Aristotle (1976:
115) suggeststhat 'a voluntary act would seemto be one of
which the originating
lies
in
the agent himself, who knows the particular circumstancesof his action.'
cause
He arguesthat people should only be praisedor blamedfor their actions
when such
actions are voluntary. In contrast, involuntary actions are pardonedand sometimes
(Aristotle
1976: 111). If unhealthybehaviouris involuntary, it shouldnot
receivepity
be associatedwith blame.
Our attitude to certain lifestyles and behaviourmay be partially determinedby whether
believe
individual
has
in
the
we
made a voluntary choice adoptingthe behaviouror has
had little or no control. While passengerswho are injured in a car accidentcannotbe
blamed,(unlessthey have deliberatelydistractedthe driver), we might attribute blame
to those adults who take needlessrisks, and for example,drive too fast. This may be
in
today
evident
certain unsympatheticattitudestowards peoplewith conditionssuch
lung
liver
A.
S.,
I.
D.
which are sometimesassociatedwith
as
cancer,
cirrhosis, or
be
lifestyles
habits.
Blame
may attributed to peoplewho are thought to
particular
or
have madechoicesthat have contributed to their own ill health. This attitude was
for
diseases,
the
Oregon
in
treatment
the
of
cirrhosis
where
ranking of
original
evident
liver without mention of alcohol was judged significantlymore important than
has
been
It
34).
(Honigsbaum
1992:
liver'
for
'alcoholic
also
treatment
cirrhosis of the
(1992:
by
10-11),
Williams
in
British
where people
pilot studies
apparent recent
had
'not
discriminate
taken
those
care
much
to
who
against
prepared
questionedwere
health
distributing
it
health'
to
resources.
care
their
came
when
of
because
both
they
Aristotle (1976: 126) suggeststhat
virtues and vices are voluntary,
in
have
independence
the
choice
some
and
we
control
our
to
under
are, someextent,
107
of our actions. It would seemto be our choice as to whether
we eat the extra
chocolate or resist and attempt to becomemore prudent in our appetites. If
we really
become
to
thinner, and fit into the smalleroutfit, it appearsto be
want
within our
control to continue the reducing diet, or alternatelyabandonthe diet and live
with the
consequences.We blame ourselvesif we eat the extra cake,knowing that we have
succumbedto temptation and it would be better for our healthand appearanceif we
demonstratedgreater resistanceand prudence. Hence Aristotle (1976: 124)
suggests
that somepeople sometimesvoluntarily incur physicaldefectsandwe blamethem for
it. We should not blame those peoplewho are naturally ugly, but
we may feel
differently about those who becomeobeseand unattractive,,as a
result of lack of
exerciseand/or over indulgence.
Kenny (1978: 27) states that every voluntary action must be an action that is in some
by
the agent, in contrast to an involuntary action which is not necessarily
sensewanted
desired. A person may be physically compelled to move; for example, his hand is
forcefully
door
the
pushed
against
against his wishes, and this would not constitute a
voluntary action. However, Kenny recognizes that for many actions there will not be a
distinguishable mental process when a deliberate choice is made; rather we perform
many actions without conscious thought. These are choices, which are subject to the
have
in
because
he
the
agent's will
negative sense
chosen to act otherwise.
or she could
Blinking appears to be an involuntary movement, which occurs independently of any
decision making process, but which the individual can usually alter intentionally if he
be
drive
When
to
tennis,
the
many of
actions seem
a car, or play
she chooses.
we
Nevertheless,
deliberately
do
move.
we could
choose
each
automatic, and we
not
hand
if
decide
left
different
drive
in
to
tennis
play
we
with our
way or
a
choose to
needed a challenge.
Aristotle (1976: 111) illustrates the difficulty of distinguishingbetweenvoluntary and
108
involuntary behaviour with the exampleof the
sailor who jettisons his cargo in bad
weather. Normally people do not throw away their property, but if it were to save
life
your
and the lives of the crew, it would seemto be a reasonablechoiceto make.
This is a voluntary choice, becauseat the time of throwing the cargo overboardthere is
an elementof choice, and the captainhasthe power either to act or not. In the dire
circumstances,throwing the cargo overboardis what the captainwants to do.
However, he may have actedunwillingly, and regretfully, knowing that the loss of
is
decision
His
is clearly influencedby externalfactors and he can only
cargo serious.
from
limited
choose
a
number of options. In sucha case,the agentdid not
intentionally createhis limited options and we shouldrecognizetheserestrictions,
judging
his
be
It
true to saythat the sailor choosesto jettison the
actions. will
when
but
it
be
cargo,
would
misleadingto saythis without qualifying the statementand
he
'What
the
the
to
agent.
mentioning
restricted alternativeswhich were available
doesintentionally is not just X, but X-rather-than-Y' (Mackie 1977:205). In essence
there canbe no genuinefreedom in the absenceof the power to do otherwise; 'a
from
he
does
if
he
X
freely
time
the
can abstain
relevant
only at
personacts
when
doing X' (Kenny 1978: 29). In addition, in order to do X freely one must haveboth
do
X.
to
the
the ability and
opportunity not
A contemporaryanalogyto Aristotle's sailor is the hospital managerwho choosesto
be
debt.
There
from
in
trust
the
may
sackthirty employees,supposedly order to save
he
is
lin-fitedchoicesin this scenarioand yet the manager still responsiblewhen or she
has
He
the
a
made
she
than
or
options.
alternative
this
of
any
option rather
chooses
because
in
the
restricted.
options
were
some
cases
albeit
unwillingly
choice,
voluntary
limited
from
the
that
a
choicewas
When appraisingthese actionswe should recognize
blame.
from
the
or
criticism
manager
excuse
sometimes
may
number of options, which
be
is
decision,
for
the
which made,she/hemay not
While the manageris responsible
in
the
limited
situation.
for
available
the
choices
responsible
109
Of course, it is possiblethat the agentis responsibleto some
for
being
in a
extent
predicamentwhere choicesare limited. For example,if the sailor was warned of bad
but
still put out to sea,he might be partly responsiblefor his limited choices.
weather,
Similarly, the managermay face stark choicesnow becauseshe/ he did not invest in
development
budget
appropriate staff
or
management.
Adults usually make voluntary choicesabout their lifestyle, eventhough the options
be
limited,
family
have
influenced
their
them.
may sometimes
and
and upbringing may
Eating a healthy diet will clearly be dependenton the availability of reasonablypriced
fresh fi7uitand vegetables,and it may be difficult for those who are on a low incomeif
the healthy choicesare the most expensive. However, peopledo choosetheir own
diet and choosewhether to partake in risky sports. They might thereforebe held to
for
justify
if
lifestyle,
for
their
they
to
their
offer
an
explanation
or
are
unable
account
behaviour.
Somepatientshave health care needs,,which follow involuntary behaviour. The
did
injury,
head
fit,
following
not
a
with
epileptic
an
casualty
at
arrives
patient who
desirethe outcome and was not in control of his/her actions. Yet, eveninvoluntary
Did
leave
blameworthy
behaviourmay sometimesbe
us with somequestions:
and may
have
known
Should
the
about
patient
the patient take his/her prescribedmedication?
doctors
be
ignorance
or
may culpable:consider
the risks of non-compliance? Some
knowledge
to
keep
their
up
to
have
professional
requirement
a
statutory
midwives who
It
information.
based
be
would
date sincetheir practice must
on relevantresearchand
ignorant
the
research
they
recent
that
of
to
law,
in
were
be no defence
or morally, say
blameless.
therefore
and
for
involuntary
blamed
be
acts,
that
not
should
111)
we
(1976:
Aristotle
suggests
(nonthrough
'are
or
compulsion
under
performed
those
he
which
as
classifies
which
110
ignorance.
' Is the individual who smokesor takes recreationaldrugs
culpable)
making
decision
a voluntary
or respondingto compulsion,becauseof an addiction? It is well
documentedthat regular use of both nicotine and certain drugs
will result in
physiological changesin the body, which may drive a personto seekmore of the same
drug. Accordingly, the choice of one who has acquiredan addiction shouldbe
involuntary
classifiedas an
choice, and we shouldnot blamethe individual for the
behaviour.
associated
However, when the individual starts smoking or taking drugs,the first choicesmight
be classifiedasvoluntary, and therefore might merit blame. There is an elementof
doubt herebecausein many casesof smoking and drug use,the individual may be
immature,or be unaware of the reality of the inherenthealthrisks. I am not suggesting
that many young people today are ignorant of the risks of smokingitself, but it seems
ill
health
believe
that
that
the
they
to
may genuinely
risks of
will not
plausible suggest
illness,
it
is
for
know
if
Even
the
they
them.
statistics smokingand related
affect
believing
figures
from
disassociate
that
the
themselves,
they
that
risks are
such
possible
for the middle aged and old, rather than the young. Alternately, they may be confident
is
difficult
do.
It
later,
to
be
say
to
that they will
people
as many
able quit smoking
drugs,
the
take
that
understand
people, who voluntarily smokeand/or
with confidence
individuals
blame
be
those
to
We
risks.
should therefore cautious about attributing
who partake.
behaviour
determine
in
the
difficulties
of particular people
There are
trying to
whether
is voluntary or involuntary. Considerthose people,who know that continued
ill
increase
the
and
of
obesity
risk
subsequent
too
will
chocolate,
much
overeating,and
benefits
long-term
for
the
keen
and
to give up chocolate
health. They may be
improved health, but be unableto resist the temptation ofjust one more chocolate
the
then
this
temptation,
to
resist
individuals
unable
are genuinely
today. If these
III
be
involuntary,
in
doing,
though,
they
classified
as
one sense
as
even
are
action should
they want. To be voluntary, it must also be the casethat they could do otherwise. It is
do.
do
individuals
difficult
know
to
than
they
to
are unable
other
whether
of course
Somecharactersmay be unableto resist the temptation, and cannothelp themselves,
desires.
term
their
to
short
whereasothers are more able control
112
4.4
Responsibility for our former
selves
Parfit (1986: 124) examinesour attitudes to time
and suggeststhat it is extremely
common for individuals to care more about the nearerfuture, than the distant future:
'Someonewith this bias may knowingly chooseto have
a worse pain a few weekslater
rather than a lesserpain this afternoon.' However,,he suggeststhat it is irrational to
less
care
about future painsjust becausethey will be in the future. The concernis not
lessbecauseof someintrinsic differencein the object
of concern- the pain itself - but
'becauseof a property which is purely positional, and which draws
an arbitrary line'
(Parfit 1986- 126).
Nevertheless,it is apparentthat many peoplewill succumbto the immediate
temptation, making a voluntary choiceto eat excessivelyor smokejust one more,
rather than adopting a healthy lifestyle, which will reducethe probability of future
illnessand suffering. It may be difficult at times to resist and evenuncomfortableto
declinethe cigarette or extra drink, but the future pain may be significantlyworse.
Parfit exploresthe motivational makeupin which the individual discountspleasures
and painsthat will occur on future Tuesdays(1986: 124). If one is future Tuesdayindifferent, one will acceptthe prospect of great sufferingthat will fall on a future
Tuesdayin order to saveoneselfany amount of sufferingnow. When Tuesdayactually
both
in
but
individual
the
to
arrives,
reacts
pain and suffering a normal manner, there
be
lack
to
seems
a
of prior recognition.
Parfit's theory on personalidentity may provide a possibleexplanationfor this
indifferenceto future pains. According to Parfit (1986: 319) a person's life could be
know
identity
Personal
into
as
person
stages.
subdivided
a seriesof successiveselves,
links
later
by
that
is
to earlier person
connect
through time constituted psychological
113
identity
The
stages.
of a personis not in itself morally significant;rather it is the
psychological continuity and 'connectedness'that matter. So the elderly personmay
be
not the sameperson as the carefreechild, although there
be
may some
psychologicallinks that connectthe various stagesof the life. Theselinks would
include memory, persistenceof beliefs, and perhapscontinuity of personality.
Generallythe connectednesswill becomeweakenedover time and sometimesit canbe
by
severelyweakened physicalor emotionaltrauma suchas a headinjury, stroke,or
breakdown.
nervous
If the psychologicalcontinuity is sufficiently weakened,it is possiblefor an individual
to feel that their earlier life was alien and they may fail to identify with that earlier self
like
feet
different
feels
if
However,
may
it
a
person.
alienatedand ashamedof
one
former behaviour, it implies that one doesrealizethat the former individual was
oneself.
Parfit suggeststhat we may also feel aliento our future selves.'If we now carelittle
like
future
future
future,
further
in
the
generations'
our
selvesare
about ourselves
(Parfit 1986: 319). Parfit asksus to considera boy who startsto smoke,without
identify
does
boy
future.
in
If
this
the
not
much concernthat this may causecancer
is
in
future
his
his
to
this
future
that
someways
self
attitude
self, we might argue
with
his
by
harm
He
his
like
action of
another
will therefore
attitude to other people.
impose
it
because
is
a
This
may
that
morally
wrong
smoking
suggests
smoking.
is
imprudence
'great
Parfit
Hence
that
death
writes
on another.
prematureand painful
do
be
it
to
do
future
to
We
wrong
to
would
selves
what
our
not
ought
morally wrong.
320).
(Parfit
1986:
to other people'
identity.
Rather
Parfit's
does
claimsabout personal
Lockwood (1994)
not agreewith
is
does
identity
than
psychological
more
matter
and
believes
that personal
Lockwood
114
/
continuity and or connectednessbetweenperson stages. He suggeststhat there is a
between
the earliest action and awarenessof the developingfoetus (in the
relation
doings
the
and
womb)
and experiencesof the adult. They could be countedasthe
actionsand experiencesof the sameperson.
It follows that elderly people, who have committed a crime in youth, or havebeen
imprudent during their early years,cannot escapethe sinsof their youth. They remain
because
they are the sameperson. However, Lockwood
responsibleand accountable
(1994: 74) doespoint out that forgivenessis still possible:thosewho committedthe
in
be
forgiven.
does
He
there
to
a
morally
relevant
still
are,
sense,
sins
not therefore
imply that they should necessarilybe punishedfor former sinsor imprudence. Indeed,
blame
for
former
behaviour
immature
their
as
adolescents,and
people
we might not
learnt
from
have
they
their mistakes.
that
subsequently
accept
It is not obvious which view of personalidentity we shouldaccept. The notion of
do
in
life
idea
by
does
that
discussed
Parfit,
to
the
we
appear reflect
personstagesas
lifestyle
Our
former
from
dissociate
and
selves.
our
our presentselves
sometimes
behaviourmay changedrastically. Neverthelessin reality, we do blamepeople,and
for
behaviour
the
if
behaviour
former
their
for
their
change
and people
ourselves,
better, we give them credit- the alcoholic, who reforms surely deservesour praise,and
it would be strangeto suggestthat the former drunkardwas someoneelse. We make
keep
hope
to
individuals
to
our obligations,
lifelong commitmentsto particular
we
and
identify
the
them
as
the
know
still
they
we
that
years,
over
change
though
will
even
we
in
insurance
to
invest
futures
a
for
ensure
policies
We
and
our
plan
samepeople.
through
that
various
While
future.
move
people
may
accept
we
unancially secure
C-.
that
the
so
they
people,
same
different
life,
remain
priorities,
and
roles
stagesof
with
former
for
their
selves.
they may be held responsible
115
4.5
Unhealthy behaviour
-i ustification and excuses
Even if individuals have contributed to their disease
and needfor healthcareby their
behaviour,
their behaviour may still in somecasesbejustified. in the
own voluntary
particular circumstancesof the situation, it may be right to take risks with healthin
fulfill
to
order
other competing obligations. For example,the firemanor parentwill try
to rescuethe child from the dangerof a fire, knowing that there is a great risk to their
health.
In
own
a similar way, the seacaptainmayjettison his cargo in the storm in
order to savethe ship and crew. This behaviouris justified in the particular
circumstancesand we may offer praiseand congratulationsaccordingly.
However, for the majority of individuals who adopt an unhealthylifestyle andtake
known risks with their health,the behaviour cannotbejustified becauseof competing
obligations. Individuals who chooseto indulge in smoking,overeatingor dangerous
however
sportsmay
offer a variety of excusesto explaintheir behaviourand defend
their conduct. They will admit that their behaviourwas wrong, indulgent,andweakbut
willed,
claim that it was excusable:there were extenuatingcircumstances,which
did.
degrees,
to
they
they
explain, varying
acted as
why
For example, people might claim that they were conforming to group pressureinfluenced
Alternatively,
drinking
teenagers
them.
everyone was
and others unduly
did
but
disorderly,
drunk
that
they
that
they
not understand
plead
may agree
and
were
By
drinking
drink
the
the true content of their
excessively,the
effects of alcohol.
and
teenagermay causean acute episodeof illness,but it would be wrong to attribute
blame,if the individual did not understandthe risks. In eachcase,the defencerests on
behaviour,
the
fuller
the
description
context of
which may explain,
of the event and
a
did.
behaved
they
fully
as
either
or partly, why people
116
Austin (196 1) suggeststhat in most
cases,justifications canbe distinguishedfrom
excuses. He usesthe exampleof killing, and suggeststhat when donein war, it may be
justified as the right thing to do
under the circumstances.Elsewhere,killing may be
wrong - accidentalor reckless- and individualsmay offer excusesaccordingly:they
did not realize that the traffic junction
was aheador they lost control of the car
becauseof exhaustion. Austin (1961: 125) reminds that few
us
excusesget us out of
blame completely and the averageexcusein a poor situationgets us only out of the fire
into the fiying pan.
In essence,if I am accusedof doing somethingwrong, I may answerby giving a
justification for my behaviour. I am attemptingto persuademy accuserthat my action
in
the specific circumstances.Alternatively, I may admit that the action was
right
was
did
know
illness,
because
I
I
the true
not
of an
wrong and offer an excuse. was clumsy
facts of the situation, or it was an accident,which was neverintended. By making
these excuses, I hope to convince my accuserthat I was not fully responsible for my
be
blame
should modified accordingly.
actions and any associated
Perhapsone of the most common"excuses"presentedby peopleto explaintheir
People
to
is
lifestyle
they
that
addicted
are
physically
claim
addiction.
unhealthy
behaviour
Compulsive
those
actions,which are
nicotine, alcohol and even chocolate.
in
driven by compelling physicalor psychologicalneed- are not voluntary character.
his
her
force
beyond
internal
by
is
driven
or
control andthe
to act an
The individual
individuals
blame
We
involuntary.
be
not
should
as
therefore
classified
action should
justify
individuals
to
follows
it
that
such
are not required
for involuntary actions and
behaviour.
defend
further
their
to
do
to
excuses
offer
they
need
not
actions and
be
drugs,
take
may voluntary and
recreational
However, the initial choice to smoke,or
held
be
they
dangers
responsible
partly
may
so
of
addiction,
the
people are warned of
117
for this behaviour. In addition, somepeople are successfulin breakinghabits
of a
lifetime, and they do give up smoking and/or alcohol. While peoplemay 'say' they
are
it
addicted, appearsthat the individual doeshave somecontrol over whetherthey
indulge
in
drinking.
to
It may be difficult for the individual to
continue
smoking or
behaviour,
but
it
is
the
that
there
give up
unhealthy
seems
a voluntary elementto this
behaviour. Addicts can seekhelp from rehabilitation services,treatmentfrom medical
from
in
or
support
professionals,
psychologicalcounsellors, order to attemptto change
their behaviour. Yet, perhapsthose who do manageto give up unhealthyhabitshave
'stronger' charactersand more will power (better genes)than otherswho cannotresist
temptation. How do we know that those who fail canreally help themselves?
Glover suggeststhat self-control is evidentwhen the individual is ableto alter his or
her behaviourfollowing information or changedcircumstances.The alcoholic or drug
in
behaviour
is
kleptomaniac,
indeed
their
to
the
unable make choicesabout
addict, or
'Sometimes
do.
(1970:
Glover
66)
help
they
a
writes
what
specifiedareasand cannot
he
is
identify
does
he
that
is
intention
with, or endorse,and one,
not
one that
person's
his
intention
drug
A
be
to
pursue addictionmay
addict's
without.
would prefer to
his
intention,
is
he
it
kind.
Then
and
be
of
altering
this
capable
not
appears
often of
blame.
'
from
him
lack
this
of capacitymay well exempt
being
being
between
distinction
open
the
and not
There is, however, no sharp
statusof
drive,
is
to
to persuasionand it is difficult to saythat a person responding a compulsive
limited
for
time,
their
a
While
addictions,
irresistible.
is
somepeople can control
which
is
'A
(1970:
99)
Glover
not
help
man
themselves.
writes
be
to
unable
others appearto
The
'
day
of
addiction
drinker
nature
the
heavy
alcoholic.
an
day
next
and
merely a
one
individual
beaccepted
an
therefore
excusing
degree
as
be
may
and
may a matter of
idea
having
the
to
adopt
from responsibility, partly or fully. This conclusionavoids
has
the
he
addiction.
over
that
no
control
she
or
fully
is
or
accountable
that the addict
118
I do not want to suggestthat becauseaddiction may excusesomebehaviourrelating to
tobacco, drugs and alcohol that it also releasesone from responsibilityin other areasof
behaviour. Alcoholics, who chooseto drive having consumedexcessivealcohol,will
for
In
legally
be
the
their
caseof alcohol
actions.
morally
responsible
and
still
5,
dependence,or indeed any other addiction we may be forgiving and supportivein
behaviour
but
the
seriouslyendangersothers.
not where
somesituations
for
their
legally
actions
held
be
responsible
will
fund
their
cravings
to
Drug addicts who steal
119
4.6
Should we blame people for their
unhealthy lifestyle?
Even in caseswhere there are indicationsthat peoplehave
contributedby their actions,
to the developmentof their illness or injury, it doesnot follow that people
shouldbe
blamedfor the harm that hasresulted. A distinction shouldbe
madebetweencausal
liability
responsibility and
responsibility. In the former one merelytries to establisha
but
in
liability responsibilitythere is an attemptto detern-fine
causalconnection,
is
who
to be praisedor blamed,rewarded or punished. We may evenfeel that the individual
be
blamed
in principle, sinceno relevantjustification or excusecan defendthe
should
behaviour.,and yet think that it would be wrong to blamein practice. The individual
becomes
ill
following
who
recklessbehaviourmay alreadyhave sufferedin excessof
blame
feel
that
any
we might
was appropriate.
The following scenarioillustrates the distinction betweencausalr9sponsibilityand
liability responsibility: someonemay have causedan accident- the vaseis smashedon
the floor - but we do not attribute blame or punishmentif the individual was unableto
has
fit,
falls
Consider
their
the
control
an epileptic
onto the table
actions.
personwho
floor.
he
We
that
the
to
to
the
or shewas causally
might say
and causes vase crash
blame.
(We
but
for
broken
to
the
might
responsible
we are unlikely apportion
vase
feel differently if he or shewas a known epileptic who had deliberatelychosennot to
be
The
the
take the prescribedmedication).
epileptic personshould contrasted
caseof
it
deliberately
throws
the
to the scenarioof an adult who
at an
picks up
vaseand
irritating dog. We would considerthis adult was responsibleand liable for his or her
be
behaviour
judge
to
this
if
actionsand no excuseswere offered, would probably
blameworthy and cruel. Our preciseresponsewill dependupon the context of the
/
demands
for
in
it
compensation.
situation and may result sanctions,penaltiesand or
120
In this section, I wish to examinewhether
hold
we should
peopleaccountablefor their
behaviour.
Do prudent people deserve6 accessto health care
unhealthy
andtreatment
in preferenceto others, who have taken known
Should
risks?
we give priority and
immediatetreatment to those individuals
have
who
adopteda healthylifestyle, because
of the 'Restoration Argument'? Finally, do the risk takers deserveany punishment?If
this questionis answeredin the affirmative, then what sort of punishmentwould be
appropriate?
Deservingis associatedwith doing.7 When we saythat a persondeserveshis or her
success,we are sayingthat it was not due to luck or favour that things went well, but
it
his
that
the
rather
was
result of
or her own efforts or characteristics.What people
deservedependsupon what they have done in the past. We can saya persondeserves
promotion and success(it would be fitting for him to havethis reward) but this is not
the samething as sayinghe can claim promotion as a right. Similarly,the defeated
Member of Parliamentmay have deservedto win, becausehe worked excessivelyhard
for his constituency,but he is not entitled to the position, unlesshe gainsthe most
(1970:
Hence,
Feinberg
86) statesthat "deserve," "fitting, " and "appropriate"
votes.
in
"right,
"
"rule,
"
"entitlement,
the
terms
are contrastedwith
and
and are used
different contexts.
Desert claims do not as such establishobligations on others (Sher 1987). If we saythe
keep fit enthusiastdeservesto be healthy, or that the hard working studentdeservesto
is
is
high
do
to
to
take
steps provide what
not meanthat anyone obliged
get
grades,we
deserved. Similarly, there is no legal obligation to punishpeople, evenwhen it appears
laws.
local
have
deserved
there
rules or
that they
are established
punishment,unless
health
in
lower
be
the
deserve
Do somepeople
care
allocation of
to
priority
given
NHS,
lifestyle?
In
the
because
resources
current
where
their
unhealthy
of
resources
desert.
focusing
the
This
0.
(1999)
concept
of
on
of
readings,
collection
Pojman L. P. McLeod
121
limited,
decisionshave to be madeabout
are
who gets priority and accessto immediate
care. Those who do not get priority for treatment and haveto wait are
being
not
punished. Rather it may be an unfortunate consequenceof the limited resources
available. Doctors have to make difficult decisionsabout which patientsaretreated
with the availableresources,while delaying,or denying,other patients.
That those deniedtreatmentsare not being punishedcanbe illustrated by
an analogy.
Considerthe employerwho has severalstaff but only
one seniorposition to offer for
promotion. The employerhasto chooseone of the staff for this post and he/shewill
probably choosewhoever he/shethinks is the most highly qualified personfor the post.
The intention is to choosethe best candidatefor the job, and not to punishthose
membersof staff who are not promoted. Considerthe university, which requires
certain examinationgradesas a condition for admission. There is no intention to
punishthose candidates,who do not successfullyachievethe gradesand are
subsequentlyrejected.
As Feinberg (1970.67) suggeststhe point of competition is to single out a winner, not
to penalise the losers. Certainly failure to win a prize may be unpleasant and
but
intention
is
losers.
for
the
to
the
awarding
unwelcome,
of
prizes not
cause suffering
In contrast, an essential and intended element of punishment is that the victim be made
to suffer for their former wrongdoing.
It is evidentthat we often do things to otherswhich they do not welcome,and may
is
deprive
harm
In
there
them
no
of enjoyment. many situations
evencausethem
or
Giving
intention,
is
to
there
punish.
unpleasant
previouswrongdoing and
no reason,or
is
is
injection,
the
to
protesting child not a punishment,and not
medicine,or an
is
If
that
the
the
medicine a
child perceives
associatedwith any previous wrongdoing.
him/her
to
otherwise.
punishmentone would make strenuouseffort reassure
In situations of scarcity, a delay or withdrawal of treatment, may reflect a decision to
have
been
have
the
individuals
prudent
and
consequently
to
those
who
give priority
FeinbergDoing andDeserving1970
122
best clinical prognosis. Decisions about
be
patient
which
should treated,when only
be
one can treated, should not be basedon desert. Ratherthesedecisionsshouldbe
basedon a number of other criteria, including medicalneed,clinical
and cost
8
desire.
It is well establishedthat the outcomesof surgery
effectivenessand patient
intensive
therapy are more favourablefor those individualswho are non-smokers,
and
within normal weight range and are physicallyfit. While current healthstatusmay be
indication
be
an
of who should given priority, there is no needto enter into the
9
lifestyle
behaviour.
problematic assessmentof previous
and
However, individuals who voluntarily adopt an unhealthylifestyle andtake known
health
harming
their
themselves,but also harmingothers,who
risks with
are not only
have
increased
health
to
to
the
pay more meet
may
care costs. In addition, the
be
liver
longer
transplant
alcoholic who needsa
may use scarceorgans,which will no
disease
developed
liver
failure
for
have
through
those
unrelatedto
who
available
lifestyle.
10
The 'Restoration Argument, ' suggeststhat smokers and heavy drinkers should have
less
deserving
because
health
they
are
their entitlement to
service resources reduced
than those who become ill through no fault of their own. In essence,the argument
budgets,
limited
Given
health-resources
than
'Smokers
non-smokers.
need more
states
(according
to
between
need) or reducing
treating
equally
everyone
we must choose
by
be
harmed
former,
If
the
non-smokers will
choose
we
entitlements.
smokers'
if
for
less
than
be
them
because
no
one
there
available
resources
will
others' smoking,
for
health
So
255).
non(Wilkinson
1999:
the
resources
care
of
quantity
smoked'
had
if
been
have
it
level
not
smokers
be
that
to
would
which
smokersshould restored
demand.
generatedextra
(1998)
the
Glannon
(1994)
restoration argument.
Smart
including
support
Writers
and
it
behaviour
former
for
drinkers
heavy
their
and
It is not about punishing smokersor
'I have discussedthese criteria in Chapter 2
9 The problems of assessingprevious lifestyle will be examined in chapter 6
Glannon
1998
Smart
1994
1999,
by
Wilkinson
described
and
been
10 The restoration argument has
123
focuseson preventing harm to third
parties so that there can be no accusationsof
paternalism,where the intention is to protect the individual from his her
or
own
decisions. However, I am concerned
first
the
with
premise- that smokersusemore
health resourcesthan non-smokers. There is
"
recent empirical evidence to suggest
that this is not the case:smokersdie at a younger age
hence
do not needhealth
and
careresourcesthroughout their old age. Berendregt,Bonneux, and van der Maas
(1997) concludethat if people stoppedsmoking,the long term
health
costsof
care
would rise. In addition, smokersand heavy drinkers pay taxes,which contributesa
considerablesum of money towards the treatment of the anticipatedhealthproblems.
While Wilkinson (1999: 255) acknowledgesthat the restorationargument
could be
appliedto any group of risk takers, it appearsthat smokersand heavydrinkers are
frequently cited. It is apparentthat valuejudgementsare being made
about the worth
of only somerisky lifestyles, as certain behaviouris selectedwhile other risky
behaviouris ignored. Should non-virgins12or parents13pay for their anticipated
increasedhealth care costs? Indeed Wilkinson suggeststhat you might run the
restoration argumentin reverseand suggestthat non-smokersshouldcompensate
smokersby having their entitlementsreduced. Any policy basedon this argumentmay
thereforeraise pragmatic difficulties and result in practices,which are intuitively
unacceptable.
Proponentsof the restoration argument,suggestthat it is not aboutjudging the merits
of certain lifestyles, or punishingthose who adopt unhealthybehaviour. Nevertheless,
in practice a punitive approachis sometimesexpressedtowards those peoplewho do
not adopt a healthy lifestyle and conform to the expectationsof the health care
do
blame
Anecdotal
that
those
professionals.
staff
sometimes
accountssuggest
judged
by
do
For
behave
the
patientswho
professionals.
not
appropriately,as
injure
by
themselves
taking
those
example,
patientswho smoke,or who repeatedly
diet,
fail
treatment
to
or
are sometimes
overdoses,or
comply with prescribedmedical
11Barendregt, Bonneux, van der Maas The health care costs of smoking, The New England Journal
1052-1057
(15)
1997,337
ofAledicine
12 McLachlan Smokers, virgins, equity and health care costs Journal ofMedical Ethics 1995: 2 10
13Wilkinson Smokers' Rights to Health Care Journal ofApplied Philosophy 16,3,255
124
in
criticized casualtydepartmentsor surgeries,and madeto feel uncomfortableabout
their behaviour.
Such expressionsof blame and scolding may be seenas a kind of informal punishment,
(Mackie 1977: 209) and may be used as an attempt to modify a patient's behaviour. In
addition, there are reported caseswhere patientsare deniedtreatment,or given low
lists,
priority on waiting
as a result of their smoking or other unhealthybehaviour,
(Hall 1993: 4; Rogers L. 1993:1). While doctors might suggestthat decisionsabout
treatment are basedupon clinical needand predicted outcomes,and managersmight
talk about setting priorities, it is possiblethat patientsmight feel that they arebeing
in
for
former
lifestyle.
I
the
therefore
their
examine notion of punishment
will
punished
be
if
it
determine
behaviour
in
to
to
would ever an appropriate
order
relation unhealthy
lifestyle.
have
for
those
adoptedan unhealthy
who
response
If I am responsiblefor what I do, it follows that I may be praisedand sometimes
blamed,
be
bad,
I
if
for
may
rewarded my good actions, and conversely my actionsare
infliction
deliberate
involves
Punishment
the
of
punished.
sometimes
and
reprimanded
deprivation
be
it
inherently
some
of
a
or
painful
either
may
unwelcome;
something
be
to
the
definition,
is,
by
to
agent,
Since
rational
unwelcome
meant
punishment
good.
is
In
it
is
imposed.
it is necessaryto justify why
most situationspunitive action
did
because
such
I
to
you
room
your
you
sending
am
associatedwith an explanation:
three
to
months
found
sentenced
accordingly
and
of
guilty
and such;you are
......
individual
the
that
is
imposed
imprisonment. Punishment
on accountof somewrong
hopes,
is,
be
hasallegedlydone, and the associationshould communicatedand one
the
to
is
person
addressed
In
primarily
understood. this way punishment a message,
learn
that
by
importantly
may
also
who
but
others,
did
overheard
and
also
wrong,
who
family
be
the
that
or
is
the
doing
to
community,
present
this wrong
unacceptable
society as a whole.
in
terms
been
of
has
mainly
traditionally
considered
for
Thejustification
punishment
In
142).
(Glover
1970:
and
utilitarians
between
retributivists
the
of
claims
choosing
be
doer
deserves
to
unless
punished
the
that
wrong
essence,the retributivist claims
125
there are relevant excusesor justifications to explainthe behaviour. Accordingly,
wrongdoers should be 'paid back' for their wicked deeds(Rachels1997:470). and it
follows that there should be somesort of equivalencebetweenthe offending
act and
the subsequentpunishment. It is not only that punishingthose peoplewho commit
crimes such as murder and rape allayscertain vengeful feelingstowards wrongdoers,
but it is also a violation of justice if they are allowed to walk away freely as if they had
done nothing wrong. Sincea wrong hasbeendone, appropriatesufferingfor the
follow
it,
is
in
the notion of an eyefor an eye and a
offender should
reflected
which
tooth for a tooth. We might, however, feel uncomfortablewith this idea of retribution
it
in
that
may result unnecessarysufferingfor no apparentgood.
and suggest
The retributivist view is essentiallybackward looking and is therefore sometimes
justified
if
is
it
the
that
punishment
contrastedwith
utilitarian approachwhich suggests
individuals,
/
deterring
in
the
other
wrongdoer, and or
results preventing or reforming
from indulging in the samewrong doing, in the future. The focus is rehabilitationfor
the offender and deterrencefor others, who are informed of the punishment. For
from
drinkers
has
deterred
driving
license
losing
over
many
a
example,the prospect of
indulgenceof alcohol. The utilitarian might suggestthat withholding medical
is
justified,
lifestyle
has
from
individual
the
treatment
adoptedan unhealthy
who
becauseit will encouragethe individual, and others,to avoid known hazardsand adopt
is
little
this
to
lifestyle.
healthy
However,
assertion,
there
support
evidence
empirical
a
if
deterrent,
treatment
it
the
that
will act as a
medical
of
withdrawal
and seemsunlikely
individuals
to
has
disease
developing
modify
the prospect of
not alreadypersuaded
its
delaying
treatment,
with
medical
their behaviour. In addition, withholding or
the
good
of
potential
outweighs
which
misery,
associatedsuffering, may causeundue
behaviour.
health
related
changingpeople's
if
be
justified
and only
Honderich (1969: 3 1) proposesthat a man's punishmentmight
to
the
his
(2)
equivalent
has
behaved
if '(1) he
penaltywill give satisfactions
culpably,
imposed
be
those
it
to
(3)
who
offenders
other
on
has
he
similar
will
caused,
grievance
knew
for
his
the
he
(4)
of
and
action
was responsible
havecausedsimilar grievances,
(5)
nonunlike
and
and
penalties,
offences
of
system
a
possibleconsequencesunder
126
offendershe has gained satisfactionsattendanton the commission
of an offence.' I
wish to examinewhether thesejustifications would constitute adequate
groundsto
punish individuals by withdrawing medicaltreatment,becauseof their
previous
behaviour.
unhealthy
In relation to the first justification: hasthe individual
who adoptsan unhealthylifestyle
behavedculpably? In the majority of casesit
be
impossible,
will
or exceedingly
difficult, to determinewhether individuals are liabilityresponsiblefor their health
behaviour.
In many casesindividuals may be ableto presentreasonsto
related
excuse
their actions, and we may feel uncertain about whether the individual could have
acted
otherwise. The assessmentof responsibilitypresentsdifficulties in practice,
particularly in relation to lifestyle and health relatedbehaviour.14For example.are
individuals responsible,or partly responsible,for their diet or
will their family
upbringing, culture and socio-economiccircumstanceslargely determinewhat they eat
drink?
Nicotine is known to be addictive, doesthis excusethe young manwho
and
startedsmoking in his early teens,before he fully understoodthe consequences
his
of
behaviour?
The idea that withdrawal of medicaltreatmentwill give satisfactionequivalentto the
does
grievancescaused
not make sense,becauseindividualshaveinvariablyharmed
themselves,by adopting an unhealthylifestyle. It is not clear who will be given
by
satisfaction, the withdrawal of medicaltreatmentfrom those patients,who are
judged to have contributed to their illness.
The third requirementfor punishmentto be justified, proposedby Honderich,presents
the idea of parity of punishmentbetweenoffenderswho commit similar crimes. In the
from
individuals,
be
treatment
there
caseof withdrawing medical
can no guaranteethat
the outcomeswill be similar. Somepatientsmay die while waiting for treatment,as in
the unfortunate caseof Harry Ephick (Iliffe 1993: 5), while others may experienceno
inconvenience
because
delay.
Underlying
the
than
of
more
mild anxiety and slight
14 Further discussion about the difficulties of assessingwhether a patient is responsiblefor his/her
health status will be developed in chapter 6
127
pathology, and genetic predisposition,will largely determinethe effect of delayingor
withdrawing treatment and it may not equateto previous lifestyle. There are many
heavy smokers,who suffer no adversesymptoms,and would not be punishedin
any
by
a policy, which suggestedtreatment shouldbe withheld, or delayed,from
way,
smokers.
In relation to the fourth justification for punishment,as proposedby Honderich,we
if
individuals
should ask
who smoke,overeat.,or drink excessivealcohol know that
they may forfeit future accessto health care? It is not clearthat they havebroken any
have
rules, and successivegovernments
repeatedlyreassuredthe public that healthcare
be
Act'
NHS
Neither
'Ae
AWS
to
to
the
available all, according clinical need.
on
will
(1979) or 'The Patients Charter' (1991) or 'The New NHS: Modem. Dependable'
(1998) suggeststhat those peoplewho adopt unhealthybehaviourwill be treated
differently from any other patients. If the intention is to punishpeoplefor their
desirable
behaviour,
it
to
provide clear guidelines,
and
necessary
would
seem
unhealthy
be
behaviour
that
peoplecanmake
so
punished,
will
criteria,
about
which
and explicit
decisionsabout how to behave,with this knowledge.
The final justification for punishment,in this list, suggeststhat offendershavegained
it
is
While
have
from
not experienced.
their offencewhich non-offenders
satisfactions
have
behaviour
enjoyed
that
adopt
unhealthy
people
who
possible,and even probable,
illness
from
be
the
here,
is
they
may now suffering
there
time,
and
guarantee
no
a good
is
It
from
have
their
not
disease,
overindulgence.
resulted
partly
and
which may
justifiable to add further suffering by delayingor withholding medicaltreatment.
is
it
lifestyle:
former
for
be
In essence,patientswho are ill shouldnot punished their
difficult to justify punishmentgenerallyand there are real concernsabout withdrawing
be
Such
unduly
from
would
action
those
delaying
needs.
medical
with
treatment
or
important
(1970:
153)
Glover
makesan
harshand contrary to the values of medicine.
for
if
justified
is
there
grounds
'punishment
good
are
only
he
that
point when states
less
in
the
causes
punishment
question,
aims
thinking that, as a method of achieving
doubt
be
little
'
There
that
can
harm than any other equally effective method.
128
withholding or delaying medicaltreatment will result in anxiety and
potential suffering,
both for the patient himself,
and perhapsfor relativesand ffiends.
If we say individuals deserveparticular penalties
or punishments,it suggeststhat they
havebehavedculpably and that there shouldbe
somerelationshipbetweentheir
culpability and the distressof the proposedpunishment. There shouldbe some
'equivalence' (Honderich 1969: 15
between
the
wrongdoing andthe proposed
-23)
punishment. Contemporary society usually apportionsgreaterblamefor a violent
assault,than for a minor theft such as shop lifting, which is reflectedin the penalties
imposedby the judiciary for such actions. Yet,,when considering
culpability we do not
only considerthe resultant harm of the action, sincewe are also concernedto
detern-fineif the individual was responsiblefor his actions. Greaterculpability is
intentional
to
attached
and plannedacts of violence, as contrastedwith accidental
injury, such as that causedby carelessdriving. HenceHonderich (1969: 16) writes
'The culpability of an offender in his offence dependson two things: the harm caused
by his action and the extent to which he canbe regardedas having actedresponsiblyý
Indeed,we should questionwhether it is ever possibleto fix a penaltyor punishment
distress
has
whose
someequivalenceof that causedby the offence. Distressis clearly
difficult,
it
is
if
how
harm
impossible,
determine
to
subjectiveand
not
accurately
much
is causedto any individual. For example,considerthe manwhose car is stolen:to
bus,
be
degree
he
harmed?
is
He
the
to
travel
and replace
on
may, after all, able
what
the car with his insurance,but he may feel that the loss of his car amountsto more than
the loss of the ability to get from A to B.
It is not at all obvious that the personwho hasled an unhealthylife, and hasbeen
health
forfeit
future
deserves
disease,
to
to
care.
unfortunate enoughto succumb
Rather, we might considerthis a severepenalty, out of proportion to any supposed
hurt
deliberately
individual
has
The
has
someone
taken place.
not
misdemeanorthat
he
imprudent,
to
been
have
he
succumbed
as
or
weak
willed
unwise,
else;rather may
by
department.
The
effectsof
a
marketing
temptation, often plannedand orchestrated
be
In
for
chocolate
and
should
not
underestimated.
cigarettes
alcohol,
advertisements
129
individuals
addition,
may have beenignorant of the facts, or have deniedthe reality of
the inherent risks of their behaviour. In many cases,we may feel that theseindividuals
but
is
there
naive,
are
no reasonto suggestthat they deservepunishment. Indeedthe
individual who developslung cancerfollowing yearsof smokingmay feel he or shehas
alreadymet with sufficient suffering.
We should therefore feel uncomfortable about suggestionsthat individuals 'deserve'to
forfeit health care, becauseof their former unhealthybehaviour. There are difficulties,
both in terms of determiningwhether individuals are responsiblefor their actions,and
in respectof the so-calledpunishmentbeing equivalentto the 'offence' comn-fitted.
Indeed,the idea of punishing anybodywho is ill and sufferingfrom a disease,which
for
justification
is
The
treatment
punishmentpresupposes
repugnant.
requiresmedical
broken
deliberately
has
done
has
individual
an establishedand
that an
wrong, and
have
homes
in
individuals
their
the
known rule. Those
not
own
privacy of
who smoke
been
have
They
health
have
ignored
if
may
broken a rule as such, even they
warnings.
individual
Similarly,
done
the
have
but
who
they
wrong.
not
unwise or weak willed
/
he
broken
has
day
she
a rule which
fails to eat five piecesof fruit or vegetablesa
not
behaviour.
be
it
follow,
is obliged to
sensible
although would
discourage
to
unhealthy
There are alternative approaches,than the use of punishment,
behaviour. Theseinclude health educationand promotion, which are not associated
total
In
the
of
prohibition
distressing
addition,
effects of punishment.
with the
be
nicotine
reducing
of
method
effective
cigaretteproduction would arguably a more
behaviour.
for
their
previous
smokers
illness,
penalized
than
any systemwhich
related
for
behaviour
form
to
of punishmentor punitive
Thesestrategies" are preferable any
health.
their
thosepeople who take risks with
15These strategies will be explored in the next chapter.
130
Chapter Five
HEALTH
PROMOTION
ACCEPTABLE
THE
-
5.1
The value of health
5.2
Health promotion and health education
5.3
Persuasionand Manipulation
5.4
Coercion
5.5
Legal Prohibition
5.6
Is paternalismjustified in health care?
131
LIMITS
5.1
The value of health
We can assumethat individuals
would normally chooseto be healthyin preferenceto
being ill or unwell health is
is
an
asset,
which
welcomed evenif peopledo not always
recognizeit, until their health is impaired or threatened. The British governmenthas
unequivocally statedits commitment 'to the pursuit of healthin its widest sense"
(Department of Health 1992: 2), but doesnot
clarify exactly what it meansby this
assertion. Indeed.,health is notoriously difficult to define and a variety of different
definitions are presentedin the literature.' I do not intend to
explainthe merits of
thesecontendingdefinitions, sinceI am only concernedto makethe point that health
(however defined) is a valuablegoal for individuals and the community
as a whole.
Aristotle statesthat there are somethings in life, which we actually ought to desireand
health
learning
(Aristotle
1976: 115). In addition, Plato argues
cites
and
examples
as
that somegoods 'are worth choosingnot only for their consequences
but also, and far
more, for themselves.,suchthings as sight, hearing,intelligence,health, and all other
qualitieswhich bring us a real and not merely an apparentbenefit' (Plato 1974: 114).
Health is a value in itself and also an instrumentalvalue.,which allows individualsto
lead a full and good life. This idea is implicit in Seedhouse'sdescriptionof healthas
'the foundation for achievement'(Seedhouse1986). While ill healthand disabilitYdo
from
health
it
individual
not prevent an
achievinggreat goals, good
will usuallymake
desires.
individuals
for
their
to
easier
achieve
various
Health is a benefit for the individual and it is also a benefit for the community. It is
distress
both
disease
death
for
that
to
and premature
can cause
stating the obvious say
involved.
family,
Relationships
those
individual
are
closely
the
who
with
afflicted and
1For a helpful discussion on "What is Health?" SeeDines A. Cribb A. Health Promotion Concepts
Chapter I pages 3-19
1993
Publications
Scientific
Blackwell
Practice
and
132
ffiends and colleaguesare important and peoplevalue the bonds
and commitments,
which are formed in society. III health and the prematuredeathof a 'significant'
person affects future plans and ambitions,and may causegreat sadnessfor others.
If the population remainshealthythe costs of healthcare may be reduced,waiting lists
be
may shortened,and there might be a more prompt servicefor thosewho needcare.
The benefitsto a community whose membersare healthy are far reaching;fewer days
increased
benefits.
the
off sick,
productivity, economicgrowth and
associatedgeneral
There might evenbe more availablemoneyfor healthpromotion and healthcare.
Improved health for the community hasthe potential to reducethe financialcostsof
from
health
been
in
has
hospital
There
the
a
a shift emphasis
and acute services.
holistic
focused
towards
the
servicewhich
a more
patients,
on curing
servicewhich
includeshealth promotion and prevention of disease(Departmentof Health 1992).
This could be motivated more by concernsto reducespendingon the NHS, rather than
for
is
individual.
The
interests
for
government currently responsible
of the
concern the
incentive
financial
to
is
in
NHS
health
there
the
obvious
an
the provision of
and
care
lifestyle,
healthy
the
individuals
certain
of
risk
reduces
to
which
a
adopt
encourage
diseasesand their associatedcosts.
be
it
be
This cost-containmentargumentshould viewed with caution since cannot
health
care.
social
and
the
health
of
costs
overall
that
reduce
promotion will
assumed
demands
longer
live
and so creategreater
If people adopt a healthy lifestyle they may
health
care.
and
social
NHS
of
provider
the
alternate
any
or
on
individuals
for
both
the
is
health
wider
and
that
I
valuable
Nevertheless, conclude
community,
is
health
life
in
not alwayspreferred.
but other things
are also valuableand
in
health
the
either
risk
at
We all take part in activities, which may potentially put our
133
short or long term. Those people who participate in dangeroussports are usually
well
aware of the immediaterisks to life and limb, and there is wide publicity about the
long-term consequencesof overeating
and smoking,yet peoplecontinueto indulge
themselves. So it appearsthat health is not an overriding goal at all times. Indeed,
2
Blaxter (1990.214) has presentedempirical evidenceto suggestthat 'substantial
proportions of the population did not seehealth asthe most important thing in life. '
For somepeople it may be equally or more important to take part in their
chosen
activities, sports or adventures,so that life is pleasantand / or exciting.
While health care professionalsmay considerit important for the patientto give up
smoking or alcohol, the patient may feel that the habit is one of the few pleasuresin
life, which outweighs any harmful risks to future health. Ironically giving up smoking
lead
increased
to
could
stress,family rows and depressionfor the individual, who
might feet correspondinglylesshealthy. Compliancewith medicaladvicemight reduce
the probability of future diseasebut may 'cost' the patient in terms of increased
physicaland mental side effects. This is well illustrated by the frequentnonin
compliance the use of antihypertensivedrugs. Many patientsfind the sideeffects
distressingand choosenot to take the drugs as prescribed,despiteknowing that there
is an increasedrisk of stroke or cardiacproblems. It is not irrational for peopleto be
in
have
happier
life.
life,
to
to
order
a
willing risk a shorter
I have suggestedthat health is valuablefor both individuals and the wider community,
health.
individuals
if
is
it
to
the
therefore
community seek promote
and
reasonable
and
Education, which enablesindividuals to make informed decisionsand adopt behaviour,
information
If
is
health,
the
risks
about
praiseworthy.
given
morally
which promotes
behaviour
is
but
it
individuals
their
that
change
will
also
clear
some
of certain activities
justified
habits.
lifestyle
is
it
But
to
their
or
adopt more
many others will not change
2 Occasionally people may desire and claim ill health. Consider the person who wishes to avoid work
is
desire
Such
generally short-lived.
a
or school, or gain sympathy.
134
in
force
measures
to
by
legislation,
order
manipulate,
coerce,
or
even
to
strident
people
Qt
behaviour,
adopt
which will promote their health?
While educationwhich respectsindividual choice is widely accepted,there
be
may
more reservationsabout the adoption of any measuresor strategieswhich limit the
freedom of the individuals to choosetheir own healthrelatedbehaviour. In this
I
chapter, will clarify someof the different approaches,which might be employedto
health
individuals.
Thesestrategiesinclude health education,
the
promote
of
persuasionand manipulation,coercion, and legal prohibition. Suchapproachesare
in
evident practice, and I will therefore examinethem in turn, in order to determine
benefit
individual
/
they
the
whether or not
would
and or the communityas a whole.
Finally, sinceI have proposedthat health is an important and valuableassetfor
individualsthemselves,the question arisesasto whether paternalismis justified in
health care? Shouldthe governmentimposepaternalisticrestrictionsin order to
ignorance
foolishness?
from
lack
individuals
their
or
of control,
own choices,
protect
135
5.2
Health promotion and health education
Health promotion is a diverse, complex and multifacetedactivity, which is difficult to
define. It appearsto be an umbrella term, which hasbeenusedto cover the
fieldg
health
of
overlapping
education,prevention and attemptsto protect the public
health through social engineering(Tannahill 1984: 196). Health promotion therefore
includesa variety of activities. Theseinclude lobbying to bring about healthypublic
levels;
local
campaignsto endtobacco advertising;the
policy at governmentand
introduction of higher taxation on cigarettes;the constructionof cycle pathsandthe
fluoridation of the water supply. This broad approachto healthpromotion is
defines
health
(1987:
Green
4)
ideas
Lawrence
the
promotion
who
of
compatiblewith
health
'any
economicand
educationandrelatedorganisational,
combinationof
as
health.
"
for
behaviour
to
conducive
supports
envirom-nental
The Ottawa Charter for Health Promotion (World Health Organisation 1986)
identified five 'action strategies' for health promotion:
Building healthy public policy
individual
change
Creating physical and social environmentssupportiveof
Strengtheningcommunity action
feelings
increased
of
Developing personalskills suchas an
self-efficacyand
empowerment
patients.
with
health
the
to
partnership
and
population
services
]RIVeorienting
including
voluntariness,participation
Thesestrategiesreflect severalethical concerns
from
deliberate
A
away
move
individuals
the
community.
and
and empowermentof
is
blaming
evident.
individual responsibility and victim
different
in
defined
been
various
has
reflecting
ways
various
Health education
(1990:
28)
the
Tannahill
Fyfe
Downie,
adopt
and
positions.
underlying philosophical
136
following definition: 'Communication
activity aimedat enhancingpositive healthand
preventing or diminishing ill-health in individuals and groups, through influencingthe
beliefs, attitudes and behaviour of those
with power and of the communityat large.'
This is a broad approach,which reflects the importance 'enhancing
of
positive health'
rather than merely focusing upon diseaseprevention.
By definition, health educationimplies that individuals should chooseto
adopt healthbehaviour.
Various models of health educationare describedin the
promoting
literature. The preventive medicalmodel aimsto prevent diseaseby
giving people
information about the risks of certain behaviourand persuadingthem to
adopt a sohealthy
lifestyle (as determinedby the health careprofessionals).The focus is
called
individuals
primarily on
who shouldtake responsibilityfor their own health-related
behaviour.
Health educationcan be viewed as a processof 'critical consciousness
(Tones
raising'
and Tilford 1994: 20) which aimsto give people a deeperunderstandingof their
circumstancesand their capacityto influencethose circumstances.The emphasisis
lesson persuasionand more on support and the goal is not one of manipulationand
but,
compliance
rather, empowermentand facilitation of choice(Tones 1997). Any
individual
health
increased
the
educationstrategy,which gives
and
an
understandingof
illness,and enablespeople to take positive action to maintainhealth, shouldbenefitthe
individual and the community as a whole. Sincethe choicesof the individual are
few
be
there
respected
criticisms of suchan approach.
can
Interest in health educationhasbeenrising becausethere is increasingevidencethat
behaviour
health
the
and
are associatedwith specific
most seriousproblemsof
many of
lifestyles. Governmentstatisticsrevealthat 'Every day in Englandheart diseaseand
day
die
from
in
370
day
26
550
kill
cancer;every
perish
people; every
nearly
stroke
137
accidents,,many of them on our roads' (Bottomly 1993: 11). Many of thesedeathsare
oremature and could be preventedif individuals changedtheir behaviour,especiallyif
they stopped smoking, altered their diet or gave up driving the car.
The increasingimportance of health educationis not therefore surprising,sincethere is
for
individuals
to changetheir unhealthybehaviour,and avoid known
great potential
risks. There is empirical evidenceto show the benefitsof changingbehaviourand in
benefits
the
particular
of giving up smoking. Thosewho give up smokingfor ten years
have a risk of lung cancerthat is half that of a smoker,andthe risk of heart attack falls
to the sameas someonewho never smoked(Royal College of Nursing 1997: 6).
It is obviously important that people shouldhave information so that they canmake
decisionsabout their behaviour. People shouldbe awareof the risks, which are
associatedwith certain activities suchas smoking,rugby and excessivealcohol, so that
they can decidewhether they wish to partake. There are however,two important
issuesto recognizewhen reviewing health education. Firstly, healtheducationwill not
behaviour.
in
If
their
peopleare allowedto choose
necessarilyresult people changing
how to behave,they may continueto take severerisks, drive carswithout seatbelts,
health
their
things
to
will sometimessuffer.
and
continue smoke, and eat unhealthy
Indeed, significant numbersof the young actually take up smokingknowing that there
450
day
Britain,
health.
Every
their
childrenstart
to
an estimated
in
are seriousrisks
high
despite
to
1992)
Physicians
(Royal
College
campaigns
profile
of
smoking
illustrate the inherent problemsof smoking.
in
in
justified
local
Are the government or
adopting coercivestrategies
policy makers
in
is
health
have
behaviour?
I
that
their
a
value
argued
to
change
order make people
it
life
in
factor
the
generally,and may
itself and an important
achieving goals of
forceful
to
justifiable
to
strategy
be
a
more
persuasive
and
adopt
therefore morally
138
promote the health of both individuals and the community as a whole. There is a
convincing argumentthat health educationin schoolsabout smokingand drugs should
aim not just to inform but to change future behaviour. The intention is to prevent
children, for their own benefit, from starting thesepotentially addictivehabits. In
addition, these strategiesmay needto be forceful if they are to counterbalanceand
free individuals from the powerful affects of the family environment,
peer pressure,and
the influence of advertisingcampaigns.
There is a secondissueto recognizewhen evaluatinghealth education. Strategiesto
health
promote
should not focus exclusivelyon the educationof individuals. Lifestyle
is only one of a variety of factors, which determinehealth. Calman(1990) suggests
that there are at least five factors which interact to influencethe healthof an individual
including
biological
factors, the enviromnent,social and economic
or population
factors.,use of and accessto health services,and lifestyle. Known sourcesof illness,
housing,
local
for
suchas poor working conditions, poor
pollution, and
amenities sport
be
improved
is
irony
if
in
There
should examinedand
necessary.
an
encouraging
breath
is
bike
if
to
that
to
take
the
they
people
polluted to
more exercise,and
work,
air
the extent that it will contribute to iff health.
Health education,which emphasizesindividual responsibilityfor health,shouldnot
detract attention from the wider environment,which clearly affectsthe decisionswhich
focus
Strategies
behaviour.
health
which
related
people are ableto make about their
findings
ignore
individuals
the
the
about
causesof
all
of
most
consistent
exclusivelyon
ill health: the 'clear gradient of declininghealthwith declining socio-economicstatus'
(Campbell 1993: 21), which remainsin Britain despitethe NHS (Whitehead1987). If
health
in
interested
to
we
need
createa climatewhere
promoting
we are genuinely
individuals are enabledto make healthy decisionsfor themselves,if they wish.
139
The following scenarioillustrates this argument:members
local
of a
communitywish
to reduce the number of accidentsand harm to children biking to school. It is
inappropriateto focus exclusivelyon developingchildren's cycling
skills and
knowledge of the Iffighway Code with no correspondingattentionto
road safety
The
generally.
most effective way of reducing cycling accidentsmight be to implement
a network of cycle paths and reducethe speedof road traffic where there is no
alternativeroute. A multifaceted approachmay be desirableto reducethe rate of
accidents. In addition, it might be relevantto considerthe contentiousissueof
legislation
be
whether
should introduced in order to makethe wearing of cycle helmets
for
compulsory
children when riding bikes on the road.
Governmentpolicy recognisesthat there hasto be a balancebetweenwhat individuals
families
do,,
do
their
the
can
and what
governmentand other organisationscan
and
(Departmentof Health 1992). The White Paper, '7he Health of the Nation: A
Strategyfor Health in England recognizesthe importanceof the local environment,
health
individuals,
influence
the
the
statusof
and
socio-economiccircumstances,which
but there is still an emphasison people changingtheir lifestyle. The potential problem
issue.
blaming
therefore
still remainsan
of victim
In conclusion,the practice of health educationis widely acceptedas a strategyto
individual
the
health
the
that
are respected.
choicesof
on the assumption
promote
health.
improving
to
is
However, education not always effective as a means
peoplewill
health.
In
harm
their
lifestyles,
addition,
to
potentially
will
which
continue adopt
from
detract
the
individual,
focus
the
attention
which can
exclusivelyon
educationmay
healthy
to
make
issues
able
are
people
where
environment
an
of promoting
wider
decisions.
140
5.3
Persuasion and Manipulation
'Health promotion is about individuals receiving information,
assessingtheir personal
risk and then making choices' (Blinkhorn 1995: 24). If this approachis accepted,it
follows that health promotion shouldnot be about the
wholesaleconversionof the
generalpublic and it should not threaten or cajole peopleto changetheir behaviour.
This view of health promotion is evident in various theoretical accounts(Tones 1987:
41-52; Downie, Fyfe and Tannahill 1990). but in practice doctors, nursesand midwives
may adopt persuasiveor manipulatestrategiesin order to maketheir patientsadopt
healthybehaviour. In this section,I will examinewhether suchpersuasiveor
manipulativestrategiescan bejustified.
It is difficult to draw firm boundariesbetweenenthusiasticeducation,aggressive
marketing, persuasionand manipulation:all theseactivities attemptto influencethe
individuals
perceptionsof
so that they agreeto pursuea specificset of activities or
A
be
in
information
be
goals. variety of methodscan adopted practice,
can presented
in a biasedfashion, certain facts can be withheld or exaggerated,tempting rewardsmay
be offered or withheld. There are degreesof persuasionrangingfrom fiiendly
include
forceful
the tactics of the
to
encouragement more
strategies,which might even
bully. There are also different forms of manipulation,which may involve deliberately
is
deceiving
deception.
Deliberately
information
patients rarely
or
withholding specific
justifiable becauseof the potential harm to future communicationandtrust.
Individuals may be persuadedor manipulatedfor their own good, which may excuseor
justify the process. Persuasionand manipulationmay aim to changepeople's own
II
in
in
Since
persuasionand manipulationmay occur a variety of ways and
preferences.
in
health
helpful
is
it
the
to
care
particular
case
examine
a
various circumstances,
context.
141
In this section, I wish to examinethe 'Baby Friendly Initiative' BFI, which was part of
a global campaignlaunchedby the World Health Organisation,WHO andthe United
Nations Childreds Fund (UNICEF) in 1991. The objectivewas to promote 'infant and
health
through the protection, promotion and support of breastfeeding'(Murray
child
1996). The initiative focused on the care of mothersand babiesin hospitals,after
birth, sinceit was claimedthat many of the barriersto breastfeedingwere established
in this initial period. It appearsthere was an attemptto changethe behaviourof
facilitate
information
in
involved
to
than
order
choice.
more
giving
women, which
As a responseto the Baby Friendly Initiative, it was reportedthat one Health Care
Trust implementeda policy which informed communitynursesthat they shouldnot
discussformula milk and 'should not provide instructionson how to makeup feeds
idea
The
(Williams
1996:
14-15).
by
do
the
to
women'
so
requested
unlessspecifically
information
about reasonableoptions
that nursesand midwives should not give women
influence
be
their
to
to
bottle
feeding,
an
attempt
unlessrequested,appears
suchas
decisionand Emit their choices. There were also unsubstantiatedreports, which stated
15)
(Williams
1996:
bottle
feed
if
bed
to
they chose
that mothershad to curtain off the
feel
to
guilty.
and were made
feeding
'bottle
BFI,
that
should
states
Andrew Radford, ProgrammeDirector of the
bottle
He
teaching
that
16).
1996:
(Radford
be
suggests
routine'
as
not presented
baby,
feed
to
image
its
a
asthe normal way
feeding during antenatalclassesreinforces
in
the
However,,
be
statistical
reality
therefore
avoided.
and that suchteaching should
babies.
In
feed
the
is
to
feeding
the
bottle
ways
normal
of
one
that
evidencesuggests
forty
initially
feed
breast
will
percent
only
and
U.K. only sixty three percent of mothers
10).
(Jones
1996:
birth
the
feeding
after
breast
be
weeks
six
still
142
Sincethe evidencesuggeststhat the
majority of women will give bottle feeds,there
appearsto be a responsibility for nursesand midwives to ensurethat mothersare
given
accurateinformation about the safepreparationof thesefeeds. If mothersdo not have
the knowledge about sterilization and the correct methodsof preparingformula feeds
there is an increasedrisk of harm for the baby. There appearsto be an underlying
assumptionthat withholding information about bottle feedingwill in someway deter
from
mothers
adopting this method of feeding for their babies,and yet bottle feedingis
widely acceptedin society.
The most obviousjustification for thesepolicies is that breastfeedingshouldbe
it
promoted since can savemore lives and prevent more morbidity than any other
health strategy (Radford 1996: 16). Over the last two decades,there havebeena
number of researchstudieswhich show the benefitsof breastfeedingfor the healthof
both mothers and babies(Lutter 1990).Few peoplewould disputethe advantagesof
breast feeding in respectto future health of both the mother andbaby. However, I
have arguedthat health is one of a variety of priorities for eachindividual and not
it
is
In
the
necessarily supremevalue.
reasonableto give precedence
certain situations,
to other valueswhile recognizingthere may be negativeimplicationsfor health. A
in
decision
baby
does
feed
her
is
how
the
to
a social
not make
mother who considering
decision.
For
her
factors
example;she
will affect
or cultural vacuum and a number of
in
her
involve
income,
family
have
to
partner
to work to provide the
shemay wish
may
feeding or shemay be influencedby her family andthe convenienceof sharingthe care
it
is
her
feed
bottle
feed
breast
baby.
Whether
choiceand will
or
shechoosesto
of the
dependon the situation, and not entirely upon future health.
Sincethe decisionto breast feed or bottle feed doesnot solely affect the mother'sown
health, it is reasonablefor health care professionalsto emphasizethe needsof the
fed
bottle
babies
in
U.
K.
the
is
it
are
who are
infant. However,
evident that many
143
relatively healthy and eventhriving. The potential risks of bottle feedingin this
country, where effective sterilization can be maintained,shouldnot be exaggerated.If
the risk to health is minimal then mothers shouldbe ableto maketheir own decisions
without pressure,manipulation or interferencefrom health careprofessionals.In the
U. K. there is probably a greater risk for the baby travelling in a car and nobody
suggeststhat mothers should avoid taking their babieson carjourneys.
In contrast, in developingcountriesif cleanwater is not available,and sterilizationis
difficult, the potential harm to the health of babiesfrom bottle feedingmay be
in
be
justified
in
Persuasion
that
or manipulationmay
significant.
case
order to reduce
the number of motherswho bottle feed their infants, in order to protect the healthof
babiesand children. In 1981 the W.H. O. estimatedthat 1.5 million infants died each
hard
ignore
is
Such
figure
fed
breast
(Rundall
1996).
because
to
they
a
were not
year
influence
justify
the choicesof mothers.
to
policies, which attempt
and may
There is a secondargumentto justify persuasivestrategiesand the withholding of
information about bottle feeding: suchtactics are necessaryto redressthe balanceand
feeds.
formula
by
combatmany yearsof aggressiveadvertising the manufacturersof
For example,in 1990,Farleys,a British company,spentthree million pounds
health
Kemp
In
1996).
(Palmer
Ostermilk
most
contrast,
and
product
one
promoting
from
and
midwives
committed
some
'authoritiesrelied on posters and encouragement
1992:
Waterston
(Beeken
feeding
breast
benefits
and
healthvisitors to promote the
of
found
because
there
that
health
this
study
286). 1 say 'some' midwives and
visitors
health
feeding
breast
these
benefits
the
amongst
towards
of
was someambivalence
care professionals.
indoctrination
from
free
individuals
the
possibility of
Health promotion should aim to
hospitals
in
Patients
health
family,
careprofessionals.
or
by manufacturers,friends or
144
are typically in unfamiliar surroundings,anxiousand not feeling their best. The
potential for salesmen,or others, to impose a set of valuesis enormous,and new
mothers may not have the energyto resist. In recognition of the vulnerability of
mothers to advertising campaigns,hospital practice haschangedin recentyears',
representativesare no longer allowed to distribute free samplesor promotion leaflets
for formula feeds on severalmaternity units.
I would suggestthat withholding information about bottle feedingand persuading
breast
feeding,
during theseearly stagesof development,is justified in
to
mothers
order to overcomeyearsof powerful advertisingand socialpressure,in both the
developingcountries and the United Kingdom. Sincethere are a variety of different
is
be
there
to
methodsof persuasion
a need
more precise. While it is acceptableto
by
breast
the
encouragemothers enthusiasticmarketing, emphasizing advantagesof
feeding, it is unkind to bully mothersby ostracizingthem and inducing feelingsof guilt
for those who decideto bottle feed. My point hereis not that persuasionand
forms
but
that
of persuasionand
only some
manipulationare never permissible, merely
justified.
in
health
care are
manipulation
I wish to make a further commentabout the Baby Friendly Initiative. I haveargued
individuals
behaviour
trying
focus
it
is
inappropriate
the
to
when
that
of
exclusivelyon
in
is
health.
It
the
to promote
wider environment which mothers
also vital to consider
initiative
Yet
babies.
feed
how
this
decisions
their
to
merely
their
about
make
will
focus
feeding'
to
breast
trying
'ten
encourage
on
to
which
steps successful
presents
feed.
I
breast
the
initial
that
her
in
to
suggest
attempts
and support the mother
breast
long
implications
term
the
of
problems
and
wider
consider
also
campaignshould
decision.
the
feeding in the community, which may also affect
mother's
is
in
Norway
there
a policy, which allows mothers extendedmaternity
For example,
145
leave, and breast feeding is encouragedin public places;' breastfeeding
in
rates are the
region of 98.5% (Chaffer 1997: 73). In addition to focusing on the mother's
behaviour, the U. K. Baby Friendly Initiative should attemptto changethe
general
public's attitude to breast feeding, and lobby for extendedpaid maternityleave.
Finally, it is interestingto comparethe Baby Friendly Initiative with the current
health
drug
Campaigns
inform
to
the
to
the
attempts promote
of potential
users.
dangers
drugs
have
included
the
young of
of
sloganssuchas 'Just sayNo! ' On the
assumptionthat people should not inject recreationaldrugs, is it appropriatefor health
information
to
promoters withhold any
about the use of needlesand syringes? Sucha
be
is
to
there
naive since
evidencethat someyoung peoplewill
strategywould appear
does
information
injecting
drugs.
Giving
about needlesand syringes
experimentwith
in
indeed
it
be
this
the
could presented
equipmentand
not encourage use of
behaviour.
facts
about potential risks and sideeffectsof such
conjunction with relevant
In this way individuals will gain more information on which to basetheir future
decisions. Such information could prevent the spreadof FHV and AIDS and so
individuals
take
health
to
risks.
those
and
the
experiment
choose
who
of
maintain
Health educationabout the use of drugs must overcomethe powerful effectsof peer
'as
drugs
Oasis
Gallagher
Noel
idols.
When
are
says
of
the
popular
pressureand
influential
17)
1997:
(Delingpole
'
this
message
having
an
sends
tea,
a cup of
normal as
for
difficult
is
fans.
It
the
his
drugs
so-called
to
numerous
the
acceptabilityof
about
'establishment'to counter balancethis type of messagewithout soundingout of touch
be
hard
Persuasion,
may
manipulation
and
selling
the
younger generation.
with
in
drugs,
intravenous
to
harms
inherent
order
of
justified to convincethe young of the
is
it
individuals.
In
health
this
also
the
scenario,
of
prevent their use, and so promote
is
justifiable
it
to
drugs
therefore
these
and
are
addictive
that
of
many
to
relevant note
in
babies
feeding
banned
from
APs
their
3 In contrast, in the United Kingdom, women
were
1)
2000:
(Sylvester
Commons committees
146
4
try to persuadethe young not to start eXperiMenting,
In summary,health care professionalsdo adopt somepersuasiveand
manipulative
strategiesin order to promote the health of individuals. Suchmethodsmay deviate
from the ideals of health educationto respectthe patients' choice
and yet they may be
effective strategiesto improve the health of individuals and the communityas a whole.
Insurancecompaniesalso offer tempting incentives,suchas reducedpremiums,to
individuals
to adopt a healthierlifestyle, to stop smokingor keeptheir weight
persuade
within a normal range. Individuals may changetheir behaviouras a result of
persuasiveor manipulativeinterventionsand might correspondinglyimprove their
future
health.
(There is of courseno guaranteehere!)
chancesof
If mature adults chooseto continue acting in ways, which are potentially harmful to
their health, knowing and understandingthe risks, then this is their choice. Health care
individuals
freedom
have
that
the
to chooseother
professionalsmust recognize
should
individuals
health.
besides
Whether
those
who chooseto adopt an unhealthy
priorities
lifestyle should be helpedwith the costs of treatmentand care,for the illnesswhich
discussed
be
Merent
from
is
that
their
should
question,and one
choices, a
may result
separately.
be
discussed
in
4
of this chapter.
section
chugs
will
The prohibition of addictive
147
5.4
Coercion.
Should the government,,local authorities, health
or
care professionalsadopt coercive
strategies,in order to promote the health of both individuals andthe community?
Hayek (199 1) suggeststhat coercion occurs
individuals
where
are madeto do
particular things by other people. In contrast,restraint occurswhen peopleare
preventedfrom doing things that they might wish to do. If you are locked in a room
againstyour wishes,you are restrainedand it would be inaccurateto suggestthat you
were coerced. Theseare alternativeways of interfering with people's exerciseof their
free will.
Nozick (1972) suggests that coercion can occur in various forms including threats,
offers and warnings. I will examine each in turn, since all these strategies are evident
health
in
care and health promotion. According to Nozick, coercion is associatedwith
threats and with the suggestion that there will be unwelcome consequences,which the
recipient would not willingly choose. The suggestion to heavy smokers that their
future treatment and surgerymay be delayedor withdrawn is a threat. Under normal
circumstancesand accordingto rights establishedin The PatientsCharter(1992),
health care is availableaccordingto clinical needon the NHS. The threat of delayed
delayed
harm
the
treatment
surgery may cause significant anxiety and
can potentially
the individual and may even contribute to the loss of life. The doctor or administrator
health
is
depriving
threatens
to
the
the patient of a
provision of
care
who
withhold
into
in
is
to
the
giving up
patient
service,which normally offered, order coerce
smoking.
Most governmentswill refrain from imposing explicitly coercivethreatsupon their
is
health.
The
in
to
to
significant
activities
risk
exception
where
pose
citizens respect
drink
driving,
infectious
in
the
the
health
caseof
or
spreadof
the
of others, as
148
' However, theoretically, the
diseases.
intervene
in a paternalistic
governmentcould
fashion in order to coercepeople to behavein a healthyway for their
benefit.
own
Wikler (1978: 303) discussesthe idea of a 'fat tax' which would require individualsto
be weighed and taxed if overweight. If the governmentheld thesetaxesin trust and
agreedto return the money, if and only when, the individual lost an appropriate
amount of weight, it would constitute a coercive strategy. While sucha policy seems
improbable,it might be an effective strategyin making individualslose weight andit
improve
health.
their
might
prospectsof good
Many insurancecompaniesoffer private health schemeswhere the chargesare higher
for those individuals who are overweight or smoke. The pren-fiumsmay be reducedif
individuals changetheir behaviour, and can provide evidenceof a healthierlifestyle.
There is a coercive elementto suchpolicies, which may be threatening,but might
induces
be
and rewardsthosepeoplewho
alternatively viewed as an offer, which
healthy
lifestyle.
maintain a
There are situationswhere it is unclearwhether a personis making a threat or an offer
becausethe normal and expectedcourseof eventsis unclear. Nozick (1972) illustrates
Q,
drowning
boundaries
blurring
may
or
the
named
who
man
of
a
this
example
with
of
he
Q
brief,
P
boat.
In
that
to
is
in
by
P,
be
the
says
only nearby
who
may not
rescued
faithfully
first
he
if
boat
in
drowning
to
the
the
promises
shore
take
the
man
only
will
he
is
Q
threatening
P
Is
not
to
or
rescue
offering
to pay a considerablesum of money.
to saveQ?
health
is
interesting
it
the
to consider provision of private
In the light of this example,
for
health
NHS
one
care,
provision
If
or
alternate
care. there was no comparable
detain
local
Act
1984,
Disease)
a person
(Control
can
authority
a
5 According to the public Health
of
be
detained
they
For
to
a
pose
must
tuberculosis.
disease,
a
person
as
such
from
a notifiable
suffering
1435).
1999:
(Coker
to
infestion
others
of
serious risk
149
could ask surgeonswho demandedhigh feesfor their serviceswhetherthe intention
was a threat to withhold servicesor an offer to care. I suspectthat sucha questionhas
the potential to causesomeunease,and in a climate where the NHS
provision is being
withdrawn, in areassuch as cosmeticsurgery,it may be a relevantquestionto discuss,
but it is beyond the scopeof this thesis.
In the majority of casesthe distinction betweena threat and an offer is
clear. If the
predicted consequencesof the intervention are worse than thosewhich could have
been expectedin the normal or natural courseof events,the coercionis
be
to
seen
threatening. On the other hand, if the proposedconsequences
better
are
andthe
recipient welcomesthe changethen an offer hasbeenmade. Nozick suggeststhat
normally people are not coercedinto performing actionsfollowing offers, becausethey
from
the
to
the availableoptions. So offers of increased
still retain
ability choose
earnings,money and rewards are not normally perceivedasthreatening,sincemost
6
peoplewelcome them.
Nevertheless,in somecircumstancesoffers may appearto be coerciveandthere have
beenexamplesof offers where an individual haslimited choice and hasto comply or
in
States,
United
For
the
women convicted
suffer unacceptablealternatives.
example,
harming
long-term
have
been
the
their
contraceptivessuchas
of
offered
children
use of
Norplant, as a condition of probation. The alternativeis a period of detentionin
(Dresser
feasible
does
the
alternativechoice
not present
woman with a
prison, which
1995: S15-SI8).
In Britain there was concern about the morality of offering cash for human organs such
6 The Government's NHS review is considering the suggestionthat mothers should be paid to breast
feed their babies. The offer of f 10 per week would be a financial incentive for mothers to breast feed,
healthy
bottlebreast
feeding,
than
the
to
more
option
of
rather
and would encourage mothers choose
be
is
This
1).
2000:
offer,
clearly
an
which
promotes
and
choice
would
welcomed
feeding (Sylvester
be
to
does
It
coercive or threatening.
by most mothers.
not appear
150
kidneys.
If a person, who hasno money or ability to raisefunds, is
as
offered a
relatively large sum of money for his or her kidney the offer may appearcoercive
since
the individual haslimited freedom to sayno. The offer is too good to
refuseandthe
vulnerableindividual cannot reasonablybe expectedto decline. However, Steinbock
(1995) questionswhether this type of generousoffer is
coercivesinceit appearsto
increasethe choicesavailablefor the individual. She
suggeststhat the offer may
exploit the poor person and take unfair advantageof his or her situation. Assuming
suchoffers are exploitative, we rightly object to the practice,but this objectionis not
basedon the notion that the offer is coercive. One might, however, arguethat this
both
is
offer
coercive and exploitative for those who havelimited money.
The notion of warnings canbe consideredin relation to coercion. A teachercanwarn
fail
that
they
their assignmentsif they do not work harder. The intention
students
will
is to motivate the studentsto work harder and inform them of the likely consequences
idleness.
The warning doesnot appearcoerciveor threateningbecausethe
their
of
harder
luck.
When giving this
to
trust
to
studentscan still choosewhether work
or
is
informing
teacher
the
the studentsof the probableoutcomesof their actions
warning
but the announcementdoesnot alter the consequences,
or reducetheir options,
If the teachergives the studentsfalse information about their progress,the warnings
if
health
be
Similarly,
deceptive,
careprofessional
a
are
and may manipulative.
be
It
behaviour
this
the
might manipulative. could
exaggerated risks of certain
is
deception
for
health
be
the
promotion, until
nevertheless an effective strategy
discovered. In the event of an individual becomingawareof any deceptionthere may
be a correspondingloss of trust and future communicationmay be difficult.
lifestyles.
in
health
in
to
been
have
Warnings
education relation a variety of
evident
increase
in
the
television
to
depiction
campaign
The dramatic
of tomb stones
151
awarenessabout the spreadof the IRV virus warned of the possibleconsequences
of
unprotected sex. The advertisementsattemptedto make individualschangetheir
behaviour by giving information about the consequences
of suchbehaviourand
perhapsinstilling a senseof fear. The warning is not coerciveif individualscan still
make their choiceswith regard to how to behave,basedon relevantand accurate
information.
In summary,threats are coercivebecausethey reduceone's choicesand are normally
unwelcometo the recipient. Offers are not coercive sincethey do not restrict choice.
Warnings are coercive if they are deceptiveand do not portray an accuratepicture of
future events.It is significant as to 'whose will is operating,whose choiceit is,
whether the act is fully voluntary, done willingly or unwillingly and so forth' (Nozick
1972: 132),
Is it everjustifiable for health care professionalsto be coercivein order to promote
health? It is important to note that coercion in itself is not alwaysunjustified or
improper. In some situationscoercion is widely acceptedas a valuablemethodof
Robert
libertarian
for
Even
important
the
writers, suchas
community.
goals
achieving
Nozick and Hayek, accept someforms of coercion are necessary.For example,limited
taxation, compulsory educationfor the young and immunisationprogrammesare
freedom
benefits
the
because
though
to
the
of
whole community, even
justified
of the
the individual is thereby limited.
I suggestthat somecoercive measuresarejustified in health care and health
lifestyles,
improve
in
be
their
Such
strategiesmay effective making people
promotion.
but the restriction on individual liberty shouldbe recognized. There is also a needto
I
forms
not.
are
be more specific about which
of coercion are acceptableand which
justified.
For
health
threat
the
not
are
example,
promotion
proposethat threats within
152
to withhold future health care is not justified becausethere is little
evidenceto suggest
that this threat will be effective in making peopleimprove their health
related
behaviour. If people have not changedtheir lifestyle because the fear illness
of
of
or
injury, it seemsunlikely that the threat to withhold treatment
be
will
effective. Indeed,
it may increasefear and anxiety for those who are having difficulties in
adoptinga
healthier lifestyle. I have arguedthat health is not the only
value for peopleandthat
they should be able to make choicesabout their lifestyle and healthrelatedbehaviour.
The use of threats in health promotion is not thereforejustified, sincethey reducethe
possiblechoicesfor the individual.
On the other hand, offers of rewards and financial incentives,in healthcareand health
promotion, are justified. Firstly, people will usually welcome such offers. Secondly,
increase
the number of availablechoicesfor the individual. There canbe no
offers will
objection to making positive offfersto encouragepeopleto adopt and maintaina
healthy lifestyle, if they genuinely increase choice for individuals. The recent
be
breast
babies
(Sylvester
feed
to
that
their
newborn
suggestion
mothers could paid
2000) is an offer which may encouragewomen to continuewith this healthiermethod
breast
feed
force
it
does
infant
feeding.
However,
them
to
and they can still
not
of
bottle feed if they wish. Similarly, children canbe encouragedto brushtheir teeth by
decay.
dentist,
if
from
tooth
they
the
avoid
offers of stickers and posters
Ty-
in
justified
the
probable
people
of
warning
also
are
care
professionals
Health
is
information
behaviour,
the
that
accurate.
providing
consequencesof their risky
ignore
behaviour
these
decide
their
to
Patientscan still
or
unhealthy
whether change
false
doctors
However,
or
exaggerated
should
not
give
nurses
and
warnings.
information in order to flighten people into changingtheir lifestyles.
153
5.5
Legal Prohibition
Finally, I will examinewhether the legal prohibition
of certain activities canbe
justified. The law in this and many other countries strictly regulatesthe use of certain
addictive drugs such as cocaine,heroin and ecstasy,so that useby the generalpublic is
prohibited. The legislation is basedon the belief that the use of thesedrugs is harmful
both to those who use them and to the wider community as a whole, There
are
health
hazardsfor those people,who take addictivedrugs, andthere are
recognized
for
form
in
increased
health
the
also problems
society
of
care costsand arguablyan
increasedrate of drug related crime. If the law prohibiting the use of cocaine,heroin
and ecstasywas changedto allow the use of thesedrugs, it is arguedthat there 'would
be a sharpincreasein use, a more widespreaddegradationof the humanpersonality,
and a greater rate of accidentsand violence' (Wilson 1997: 308).
There is a further argumentto justify the prohibition of addictive drugswhich alleges
that the 'addict' is not acting accordingto his or her own free will becauseof the very
have
driven
drugs.
limited
free
Addicts
they
to take the
these
nature of
choice are
drugs becauseof physical dependency.It cantherefore be arguedthat the total
future
drugs
the
these
autonomyof the personwho
prohibition of
will actually protect
drugs,
begin
at a very young age.
might
experimentingwith addictive
Nevertheless,it hasto be recognizedthat the law prohibiting the use of addictivedrugs
by the public restricts the freedom of individualsto act asthey might wish, and liberals,
Gordon
liberty,
individual
ideal
may not support sucha restriction.
of
who uphold the
Grahamarguespersuasivelyagainstthe prohibition of addictive drugs (Graham 1992:
in
law
is
little
to
the
to
that
there
He
that
28-35).
change
evidence
show
a
maintains
drugs
large
lead
the
to
drug
numbersof peopleusing
addictive
taking would
permit
(though
harm.
He
the
that
of
claims
not
all)
much
with the predicted widespread
154
resulting harm will be direct damageto the welfare and prospectsof the drug
addicts
themselves. It appearsthat the law is acting in a paternalistic
mannertowards those
individuals who chooseto indulge in taking theseillegal drugs.
Indeed, the precisenature of the harm causedby someof the
prohibited drugs, suchas
cannabisand ecstasyis not clear, and adverselong-term physicaland psychological
7
the
effects on
addict are not conclusivelyproven. In addition, the law is inconsistent
sincethe use of nicotine and alcohol are not outlawed and yet there is convincing
medical evidenceto demonstratethe potential physicallong-term harmsfor the
individual who smokes' and / or drinks 9. There is also evidenceto showthat passive
for
smoking, especially children, causesa range of adverseeffectsincluding lung
cancerand suddeninfant death syndrome(Royal College of Physicians1992).
Grahamalso questionsthe claim that drug taking is accompaniedby an increasedrate
if
it
is
level
Even
that
the
of crime.
reported
of drug offencesand relatedcrime are the
form
in
(Tonks
Graham
Britain
1992.269),
serious
most widespread
of
crime
itself
be
drug
is
that
taking
proposes
a
such statisticsshould examinedclosely since
in
be
it
is
inevitable
Thus,
that
there
an associatedrise overall crime
crime.
will
figures.
Goode (1997: 10) makesthe point that drugs are sometimesclassifiedby the law: the
7Strang, Witton, and Hall (2000) state that substantial public investment for finther researchinto the
long term use of cannabis is neededto determine the physical and psychological effects.
" Health Education Authority Fact File, Smoking and Young People HEA 1993
Doll R. Peto R. and others Mortality in relation to smoking: 40 years' observationson male British
doctors British Medical Journal 309,901-911
Evans A. E. Mathewson Z. M. 'Risk factors in cardiovascular disease' Science Progress 70, (4) 489504
'In 1991, the Centres for Disease Control estimated that tobacco smoking causesor significantly
States
'
Goode
E.
Between
Politics
United
in
deaths
the
430,000
and
annually.
contributes to over
Reason The Drug Legalization Debate Contemporary Social Issues St. Martin's Press 1997: 27
Royal College of Physicians Smokingand the Young Royal College of Physicians 1992
9 Working Party of the Royal College of Psychiatrists and the Royal College of Physicians (2000)
deaths
30,000
deaths
to
there
annually
cannabis,
are
about
attributable
there
no
are
that
while
suggest
885)
(2000:
Pelosi
in
Cited
due to alcohol.
155
drug is describedas legal
illegal.
The so-calleddrug problem focuseson the illegal
or
drugs, but often fails to include
alcohol or nicotine, eventhough the latter substances
may causegreater physicalharm than drugs such as marijuana,and are known to be
addictive. Goode criticizes the 'legalistic' definition becausehe claimsthat it creates
an artificial distinction where there is no natural or pharmacologicaldistinction
between say nicotine and the drugs, which are illegal. If drugs
defined
by their
are
illegal statusthen there will be an increasein crime merelybecause
peopleusethe
drugs.
Grahamspeculatesthat if addictive drugs were legalizedthey might becomecheaper
for
the
and
need
associatedcrimes suchas muggingsand burglariesmight be reduced.
The illegal status of drugs may therefore be a major factor in their causingsocialharm
to others (Graham 1992: 33). Decriminalizing drug use might also reducethe costsof
'0
policing and prevent the corruption and
violence associatedwith the vast profits
by
made somedealers. If drugs were legalizedregulationsto control the content and
drugs
be
introduced
to protect usersfrom the dangerous
concentrationof
could
decriminalization
drugs
In
the
these
the
products often sold on
streets.
ways
of
could
harm
for
both
the
the usersand the wider community.
actually reduce
Grahampresentsa further argumentagainstthe legal prohibition of certain addictive
drugs. He proposesthat if the legalization of drugs would lead to widespreaduseby
large numbersof the public there is a further problem. If peoplewould chooseto take
thesedrugs in the situation where there was no prohibition, it follows that any
legislation to prohibit their use is certainly an infringementof the freedom of
individuals on a considerablescale(Graham 1992: 29). Even if the use of addictive
drugs such as ecstasy,heroin or cannabisis foolish, hedonisticor physicallydangerous
II Pelosi (2000: 885) claims that 'in 1997 three quarters of the United Kingdom's estimated fl. 4bn
law
lessen
drug
to
spent
on
national
was
enforcement
and
efforts
misuse
expenditure on tackling
international supply'
156
for the individual, those who adopt a liberal approach
may not support a legal
prohibition of such drugs.
Grahamhas demonstratedthe difficulties in justifying the legal prohibition of drugs
on
the basis of limited evidenceof the resulting widespreadsocialharm. Cudd (1997:
309-319) presentsa similar argumentsuggestingthat sincethe use of addictivedrugs
doesnot really harm others, we shouldlegalizemany drugsthat are currently illegal.
Yet many of the addictive drugs remainillegal both in this country andin the USA.
We shouldtherefore questionwhether sucha policy canbe justified on paternalistic
grounds.
Paternalisticinterventionsmay be justified if the decisionsto be madeare substantially
irreversible. If people chooseto use addictive drugsthen it may be difficult to return
to former behaviour, so that they may not have a chanceto benefit and learn from their
both
drug
decisions.
by
dye
be
In
the
the
use and
caseof
may cast early
mistakesand
influenced
behaviour
be
is
to
the
the
that
there
and
young may attracted
a risk
smoking
by peer group pressure,and it is surely permissibleto protect them fi7omstarting such
behaviour.
potentially addictive
have
do
(1997:
321-325)
Goodwin
that
one
In addition,
most people not
argues
have
over
can
change
they
which
of
preferences,
a
variety
rather
overriding preference;
individual
in
the
the
caseof
time. Someof our preferencesconflict with others, as
immediate
for
drugs)
(or
the
and
relaxation
take
pleasure
to
other
who wishes smoke
increase
in
the
to
of
but
chances
to
it
order
smoking
stop
that provides,
wishes
also
(to
first
holding
the
preference
In
healthy.
may
start
off
this
people
example,
staying
future
in
they
be
the
that
to
there
suppose
reason
good
may
yet
and
continue smoking)
if
health,
they
latter
for
the
particularly
of
ongoing
goal
develop
a
preference
may
becomeill.
157
Is legislation banning the
use of certain addictive drugs an exampleof permissible
paternalism? Despite the short term pleasureof drugs or smokingthe
vast majority of
usersprobably expressa desireto stop the habit but find it difficult to stop
oncethey
have started the addictive behaviour. It
might therefore be justifiable to legally prohibit
these drugs in order to prevent the young and susceptiblefrom
startingthe habit which
know
is
difficult to break.
we
There are other legal restrictions, which arejustified eventhough they limit the
freedom of the individual. Most liberals acceptvarious restrictions individual
on
liberty including speedrestrictions on the roads, compulsory
wearing of car seatbelts
and motor cycle helmets,and local policies introducing fluoridation of the water
supply. Thesemeasureshavebeen effective strategiesfor improving the health and
welfare of both individuals and the community as a whole, but the potential loss of
individual freedom to choosealternativeoptions shouldbe recognized. In addition,
suchpolicies allow the governmentto imposeone set of values(the promotion of
health and well being), rather than allowing individualsto maketheir own choices
about preferences.
So when is completeprohibition of an activity justified? Firstly, the total prohibition of
be
last
the
activities or
resort, adoptedwhen other
use of substancesshould only a
in
have
found
be
ineffective
health
/
been
for
to
strategies
promotion protection
is
behaviour
individuals.
It
the
preferableto adopt educationalstrategies
changing
of
based
individuals
to
on their own priorities and goals
where
are allowed make choices
if it is possible. Secondly,it is necessaryto have convincingevidenceof the potential
harmsboth to the individual, and more importantly to the wider community,before
be
in
implemented
Finally
justified
there
is
practice.
should general
and
prohibition
in
benefits
that
the
in
prohibition will result
which outweigh
agreement the community
liberty
infiingement
and any other associatedrisks.
of personal
the potential
158
The law introducing the compulsorywearing of
belts
seat
can bejustified on the basis
that there had been extensiveeducationabout the benefitsof wearing belts
little
with
evidenceof behaviour change. In Britain the law was passedin 1965to enforcecar
manufacturesto fit all new cars with front seatbelts. Therewas extensivepublicity
and education about the benefits of wearing thesebelts, including the clunk click
television campaignwith Jimmy Saville,but it was estimatedthat only approximately
20% of the population actually wore their belts during the 1970's. After
repeated
introduce
legislation an act was finally passedin 1981to makethe wearing
to
attempts
belts
of seat
compulsory. This law wasjustified on the basisthat seatbelts had been
be
highly
to
shown
effective in reducing deathand seriousinjury. Therewere not only
potential dangersfor the individual in a crashbut there were also harmful implications
for the community as a whole. Increasedhospital costs,the prolongedcare of
dependent
death
fhends
the
physically
casualtiesor even
close
of
relativesor
were all
harms.
is
It
potential
also relevantto note that the inconvenienceof wearing a car seat
belt is minimal and doesnot affect the overall goals or lifestyle of the individual.
In conclusion,there are circumstanceswhere it is justified to limit the freedomof
individuals by prohibiting certain behaviour,both for their own good and for the good
of the wider community. The government,or other agencies,shouldattemptto
fundamental
health
is
legislation
health
the
the
since
a
promote
community with
of
assetwhich contributesto the overall well-being of eachpersonand societyas a
high
be
known
to
Total
to
a
risk
activities,
which
are
certain
of
prohibition
whole.
health, can be justified but the loss of individual freedom should alwaysbe recognized,
However, where there is inconclusiveevidenceabout the effectsand outcomesof
health related behaviour, people shouldbe ableto chooseother priorities and goals
besideshealth promotion and long life.
159
5.6
Is paternalism justified in health care?
I have previously arguedthat health is valuablefor the individual but
other things are
also valuable and may be preferred; people shouldbe ableto choosefrom their own
determine
their priorities, in matterswhich primarily affect their own lives.
values and
For example,a businessmanmay chooseto pursuea high stressjob,
smokeand eat too
much of the wrong things, and take little or no exercise,which will inevitablyincrease
the chancesof ill health in the future. Nevertheless,competentadultshavea legal right
and arguablya moral right, to refuselifesavingtreatment,and can discharge
themselvesfrom hospital: life doesnot haveto be preservedover competingvalues.
In essence,people should be free from coercion or legal restrictions,and be ableto
from
their own competingvalues,providing that their actionsdo not harm
choose
idea
is
in
This
others.
expressed the much quoted phraseof John Stuart Mil
'the sole end for which mankind are warranted,individually or collectively,in
liberty
is
the
their
interfering with
of action of any of
number, self-protection. That the
for
be
only purpose which power can rightfully exercisedover any memberof a
harm
11is
his
is
to
to
own good,
others.
prevent
civilised community, against will,
(Mill
In
is
15).
1912:
relation to
either physical or moral, not a sufficient warrant'
healthpromotion, this implies that paternalisticinterventionsto protect the healthof
be
justified,
Mill
this
that
for
the
their
point
makes
own good cannot
competentadults
doctrine is not meantto apply to children or those people(with for example,learning
difficulties), who require ongoing care and must be protected from their own actionsas
injury.
well as extemal
However, Mill has no objection to vigorous persuasion,remonstration,reasoning,
better
individuals
the
to
of
ways
to
and
adopt
good
encourage
entreatingor education
behaviour
influence
to
the
of one another
he
that
life. Indeed suggests
we should seek
160
provided that individuals are ultimately allowed to make decisionsabouttheir own
in
actions, matters which primarily concernthemselves.It is also acceptableto
criticize those people who do not adopt sensiblebehaviourand are unableto resist
temptation, or are foolish. We can avoid the man who behavesin a way we do not
admire and Mill suggestsit may be our duty to caution others againstthe manwho
have
presents an example which may
a pernicious effect on others (Mill 1912: 95).
A,ccording to Mill, the personwho cannotrestrainhimself from 'hurtful indulgences'
for
faults
directly
legitimately
hands
'severe
that
the
of others
suffer
penaltiesat
may
left
bear
be
himself'
(Mill
He
1912:
95).
to
may criticized, ostracized,
concernonly
the consequencesof his behaviour. If he wishesto adopt behaviour,which harmshis
health,,this is primarily his concernand society shouldnot imposerestrictionson his
liberty in order to compel him to adopt a healthylifestyle. Peoplecanhowever,make
be
indeed
to
displeasure;
known
there
their
obligation
an
may
their views
and express
behaviour.
dangers
and possibleconsequencesof certain
warn others of the
To illustrate his argument,and the underlying principles,Mill examinesvarious
both
injurious
be
to
he
drunkenness
including
which suggestscan
practical examples
NEII
that
Nevertheless,
individual.
any
development
proposes
happinessand the
the
of
is
'illegitimate
its
(and
thereby
law which prohibits the saleof alcohol,
restricts use),
is
Each
110).
(Mill
1912:
person
interferencewith the rightful liberty of the individual'
drink
if
to
18),
(Mill
1912:
health
choose
people
and
their
own
the proper guardian of
is
their
this
choice.
primarily
excessively,
'No
drinking
that
and states
In addition, Mill. examinesthe consequencesof excessive
but
drunk,
being
for
a
policeman
or
a
soldier
be
simply
punished
person ought to
is
if,
there
If,
(Mill
100).
duty'
1912:
drunk
only
being
and
for
on
be
should punished
legal
individual,
and
the
restrictions
public,
or
wider
to
foreseeable
risk another
a
161
possible sanctionsare morally justified. Mill arguesthat certainrestrictionson
behaviour are morally pern-fissible,if they protect other
membersof societyfrom harm.
In practice today, there are laws which limit the freedom of individualsin
order to
prevent risks to the health of others; legal restrictions on drink /driving, and restricted
smoking policies are obvious examples. There are also legal requirementsfor business
and manufacturingindustriesto restrict harmful pollutants and maintaina healthy
working environment.
In conclusion,health care professionalsshouldrecognizethe inherentethicalproblems
of paternalism- people should not be coerced,or forced by legal prohibitions,to adopt
healthy
lifestyle
for their own good, If patientschooseto take risks with their health,
a
ignoring health educationand warnings,then this is ultimately their choice,because
healthis only one of many valuesfor the individual. However, healthcare
professionalsmay attempt to persuade,support, enthusiasticallyencourageand cajole
their clients to adopt a healthy lifestyle, provided that they recognizethat the final
decisionbelongsto the individual. Where behaviourmay result in foreseeableharmto
but
is
liberty
individuals,
justifiable
it
be
this
the
to
not
of
restrict
others, may
patemalism.
162
Chapter Six
CAN A POLICY, WHICH TAKES ACCOUNT OF LIFESTYLE IN THE
DISTRIBUTION OF HEALTH CARE, BE IMPLEMENTED
6.1
IN A JUST WAY?
Problemsinherent in any policy, which seeksto distribute healthcareresources
lifestyle
to
according
6.2
Should Rationing be Implicit or Explicit?
6.3
The Mechanisms of Rationing
6.4
Alternative Policy Options
163
6.1
Problems inherent in any
policy, which seeks to allocate health care
resources according to lifestyle
In Chapter Three, I discussedfour contemporary
approachesto distributivejustice and
concludedthat they did not precludethe allocation of healthcareresources
according
to lifestyle in principle. If it is not wrong in principle, it may still be
wrong in practice,
becauseit may be impossibleto introduce a fair
and workable system. In this chapter,
I wish to explore whether it is possibleto implementa policy,
which adoptsprevious
lifestyle as one of the criteria in the allocation of health
care resources, in a just way, so
that individuals are treated fairly.
In the first section, I will suggest that there are problems inherent in
any policy, which
include
lifestyle as one of the criteria in the distribution of health care
to
seeks
resources. There are difficult questionsto answer:Who shouldbe held responsiblefor
their behaviour? How do we avoid the problem of victim blaming? What behaviour
be
should included in the policy? Where do we draw the line betweenrisky but
behaviour
but
acceptable
and risky
unacceptablebehaviour? Who is in a position to
assessthe lifestyle of others? How do we avoid unacceptableintrusion into private
lives?
I will go on to examinewhether decisionsabout rationing shouldbe implicit, and
cloudedin the veil of clinical judgement, or whether they shouldbe explicit and open
to public scrutiny. Finally, I will discussthe various forms of rationing, which might be
implementedand an alternativepolicy option, which could be implementedin order to
future
health
by
individuals
the
to
costs
of
possible
make
care, paying
contribute
taxation on certain products, such as cigarettes,sporting equipment,and fast cars.
In practice, it is evident that somedoctors do considerlifestyle.,and behavioursuchas
164
smoking and alcohol consumption,relevantto decisionsabout
who shouldbe allocated
scarcemedical resources. If people make choicesthat result in
illness,or injury, and a
correspondingneedfor health care, then they shouldbe expectedto bear the
consequences.In other areasof our life, individuals arejudged to be responsiblefor
their behaviour and will be expectedto accountfor their behaviour
and acceptwhat
follows.
Yet there appearto be severalproblemsin implementing policy,
a
which adopts
lifestyle as one of the criteria for rationing limited health
careresources. Canwe
identify the individual who is responsiblefor their lifestyle
and subsequenthealthcare
needs?Are we certain that the individual madean informed and uncoerceddecisionto
adopt an unhealthylifestyle? Considerthe exampleof smoking;are we really
convincedthat the personwho smokeshasmadea voluntary choice? The young may
be unduly influencedby group pressure,while older membersof societywere brought
in
up an era when smoking was portrayed as sophisticated,both by the mediaand in
1
Smoking
is
known
be
for
individuals
to
widespreadadvertising.
addictive and
many
with particular personalities,it may be difficult or impossibleto breakthe habit once
established.We should not blamepeople for behaviour,which is beyondtheir control.
Behaviouris obviously influencedby social and cultural forces. Advertising campaigns
actively seekto influence our choices. Our lifestylesare relatedto family values,
group norms and socio-economicfactors and it may be very difficult for peopleto
deprivation
healthy
decisions
in
make
situationsof
and poor education. The
requirementsof a healthy diet, including fresh vegetablesand fruit and wholemeal
bread,may be more expensivethan alternativesand difficult to store in some
healthy
but
to
In
choices
are
circumstances. addition, many people want make
impededby circumstancesor personalcharacteristicsthat they cannot control, or can
I Royal College of Physicians (2000) described nicotine as 'a powerfully addicting drug on a par with
heroin and cocaine. Further discussion on the notion of nicotine addiction will take place in Chapter 7
165
only control with great difficulty,
While I have arguedthat individuals can and do makevoluntary choicesabout someof
their behaviour, it may be difficult to assesswhether the behaviourof an individual is
in
voluntary a particular case. Voluntarinessis a matter of degreeand we may have
doubts
individual
the
about whether
some
really could have chosento behavein a
different way. If personality characteristicsor cultural environmenthaveinfluenced
the availablechoicesfor the individual, we shouldbe cautiousabout anypolicy, which
blame
limit
and might potentially
accessto medicalcare.
apportionsresponsibility and
Daniels (1985: 158) suggests that one of the central worries about life-style choices is
that they are not 'clearly voluntary or are not ones for which we feel comfortable
decision
diminished
if
is
full
to
there
claim
no way
responsibility, even
ascribing
is
involuntary
between
dividing
line
'
The
acts not
voluntary and
making competency.
does
distinction,
draw
be
too
to
not
tendency
which
there
a
sharp
a
may
precise and
individual,
is
therefore
if
the
Even
the
and
of
control
an act within
reflect reality.
factors
by
be
influenced
it
not
to
are
which
extent
as
such
may
classified as voluntary,
individual
hold
the
to
individual,
responsible
that
the
are
reluctant
we
within control of
for the behaviour.
lead
to
has
to
lifestyle
the
potential
to
health
A policy to ration
previous
care according
behaviour,
individuals
their
focusing
rather
and
blaming,
on
the
emphasis
with
victim
be
disease.
Lifestyle
cannot
of
causes
social
and
than the wider environmental, cultural
isolated from genetic, environmental, psychological and many other contributing
lottery",
"natural
'results
the
of
factors. Childress (1982: 205) suggeststhat the
In
dissect'.
impossible
be
to
only
reality,
individual
may
choices
and
societal practices,
individuals
are
unlucky.
develop
succumb
who
and
cancer
a proportion of smokers will
it
did
to
although
they
cancer,
get
not
choose
to
have
While they may
chosen smoke,
166
doesappearthey have entereda lottery where there are increased
chancesof
succumbingto a variety of diseases.Those individuals,who actuallybecomeill, may
deserveour sympathyand help, rather than our blame.
There is a risk that the governmentand public may underestimatethe influenceof
illness
sources
other
of
such as unsafeworking conditions, environmentalpollution,
andthe effects of commercialadvertising. An emphasison individual responsibilityfor
healthmight lead to reducedconcernand expenditureon the wider environmental
factors which contribute to ill health. This would have adverseimplicationsfor
including
individuals
those
everyone,
who took minimal personalrisks.
For example,an increasedemphasison attemptsto changethe behaviourof individuals
through health educationmay detract attention from the collective responsibilityof
death
disability.
industries
The
to
the
tobacco
society minimize
car and
causesof
and
havean enormousimpact on our lives and increasedstatutory regulationsin relation to
death
in
have
premature
a greater affect reducing
safety,speedand advertisingmight
than campaignsaimed at the individual.
However, it should be recognizedthat while we may favour a policy in healthcare,
behaviour,
former
for
individuals,
this
blame
does
their
to
contrasts
which
not attribute
hold
do,
for
We
in
peopleresponsible
example,
with other areasOfjustice our society.
for their behaviour in areasof criminal and civil law. Judgementsin the courts reflect
behaviour.
The
decisions
for
their
belief
and
that people are responsible
society's
be
little
There
be
drunk
be
driver who is found to
or no
will
punishedaccordingly.
will
discussionasto whether the drinking resultedfrom social pressures,personality
have
in
drivers
Drunk
may not reality always
characteristicsor even addiction.
be
held
but
they
harm
punished
and
responsible
to
still
will
others,
accidentsor cause
do
law.
broken
People
have
the
not put
who
for their behaviour, becausethey
current
167
belts
in
their
seat
on
a car will be held responsibleand if they are injured in
an accident,
compensationwill be significantly reduced.
Why shouldthe consequencesof health related behaviourbe treated differently from
the consequencesof behaviour in other spheresof life? The answerto this question
be
may partly related to the attitude of societytowards thosewho get ill. We do not
deserve
think
that
to get ill and those who areunlucky and do become
people
generally
ill, deserveour sympathy. It is wrong to blamethesepeopleand we may rightly feel
uncomfortableabout the punitive tones of refusingtreatmentto individuals,evenif
they have indulged in certain unhealthybehaviour,or known risks.
When peopleindulge in unhealthybehaviour,they may be imprudent andunwisebut
they are not breaking any laws or widely publicized rules. They may of coursehave
disregardingguidelinesand warnings about the potential risks to health,but this is not
the equivalentof driving having consumedexcessalcohol, or taking certainaddictive
drugs,where the activity is illegal. This leavesopenthe questionof whether some
disqualifier
for
illegal,
be
to
behaviour
access
or
explicit
made
an
should
unhealthy
be
behaviour
identify
be
difficult
it
Yet,
to
should
which
might
medicaltreatment.
illegal.
made
illegal
be
boxing
debate
has
been
For example,there
should made
about whether
some
The
injury.
head
from
in order to protect those peoplewho partake
potentially serious
be
boxing
has
(1993)
British Medical Association
should criminalised,
proposedthat
deliberate,
intentional,
immoral
it
is
basis
causeof
the
that
an uncivilised and
on
However,
brains.
their
damage
to
especially
people,
and
unnecessary
undesirable
both
boxing
Warburton (1998) has arguedthat eventhough
undoubtedlyentailsrisk,
death,
damage
personal
and
brain
sports
other
many
even
and
acuteand chronic.,of
168
activities also entail risk, and yet the BMA is not proposingto criminalisethese.2 The
BMA should take a consistentapproachto sports
if
and they proposea ban on boxing,
then it follows that they should also ban other sportswhere there are
equal,or greater,
dangersfor the participants. If boxers are really made
awareof the risks, and if
children are not allowed to partake, it is difficult to justify a ban on this sport, while
ignoring other sports with similar risks.
Boxing may be a specialcasebecausethe injury is not only foreseeable,but also
intended, Gillon (1998) suggeststhat there may be argumentsto justify changing
some
boxing,
the
of
practices of
even if it is not legally banned. Safetymeasurescould be
developedto protect the individual from actual and potentially major physicalharm,
including a ban on blows to the brain or the compulsoryuse of protective headgear.
Suchmeasureswould allow peopleto continueto pursuea sport of their choice,while
from
deliberate
infliction
harm.
them
the
protecting
of physical
It is difficult to determinewhich behaviour shouldbe includedin any policy, which
lifestyle
into
health
distribution
to
take
the
seeks
accountwithin
careresources.
of
While we can estimatehow many cigarettesan individual smokes,and excessiveeating
be
behaviour
be
by
cannot
monitored so
can monitored weight checks,other unhealthy
behaviour
include
For
suchas unprotectedsex,excessive
easily.
example,should we
in
indulge
in
Those
lifestyle
the
such
peoplewho
policy?
sunbathing,and a sedentary
behaviour.
but
it
is
difficult
health,
their
to
their
monitor
activities are taking risks with
Are smokersto be disadvantagedjust becausetheir habit is quantifiable?
In reality, we all behavein ways that can potentially harm our health. Driving the car
2 Warburton (1998: 57) presents interesting figures from the Coroners' reports to the Office of
in
deaths
1986
1992,
for
three
there
Surveys
the
Population Censusesand
when
were only
years
England and Wales from boxing. In the sameperiod there were 77 deaths in motor sports, 69 in air
from
damage
is
difficult
It
horse
to
in
28
more
assesschronic
riding.
sports, 40 in ball games and
health,
far
long
than
drinking
term
to
heavy
a
pose
greater
risk
smoking
and
sports, but it is clear that
boxing or any other sport and yet they are not banned, although they are of course heavily taxed.
169
clearly presentsa health risk for many people and sporting activities suchasjogging,
hang gliding and rugby introduce both potential benefitsand risks for thosewho
is
difficult
It
define
defensiblerisks as comparedto indefensiblerisks. It
to
partake,
be
is
that
there
might argued
no comparisonbetweensmokingand driving - the former
is proven to harm health, while the later is a necessityto modem life.3 However, it is
impossibleto draw a fair dividing line betweenthose activitiesthat presentan
health
do
judgements
Value
to
those
that
and
acceptablerisk our
not.
and our own
be
'necessary'
may
appraisal
evident in our
of what constitutesa
prejudices
risk and
difficult
identify
is
behaviour.
it
be
In
to
reality, would
which
what acceptable
behaviour should be included in a policy that allocatedhealth careresourcesaccording
to lifestyle.
In addition, if previous lifestyle is acceptedas one of the criteria in the allocationof
healthcare resources,and people are deniedor given inferior healthcarebecauseof
former behaviour, it may gradually changeour attitudesto thosewho take risks.
be
inflict
themselves,
Shouldexecutives,who continue to overwork and
stresson
health?
In
for
a
such
should
their
scenario,
extreme
taking
an
risks with
penalized
If
do
a
to
'penalize'
screening?
and
prenatal
those
preventative
submit
not
who
policy
health
be
indications
despite
have
that
there
potential
may
to
a
child
couplechoose
The
health
for
a
slippery
have
of
affects
care?
to
they
subsequent
pay
problems,will
be
slopeshould not underestimated.
introduces
individuals
lifestyle
a variety of problems.
The difficulty of assessingthe
of
lifestyle
healthy
had
have
as compared
a
Is it possibleto distinguishbetweenthose who
have
doctors
the
While
lifestyle?
to those who have voluntarily adoptedan unhealthy
be
it
they
that
will
disease
treatment,
assumed
cannot
knowledge
and
about
clinical
is
it
in
itself
dangerous
is
not always a social
driving
and
3 Husak (1994) reminds us that
activity
a
because
to
people
for
trivial
or
a
party
as
such
going
reasons
journeys
made
are
Many
car
necessity.
do not,like public transport.
170
have accessto relevant information about the previous lifestyle
of others. If the doctor
askspatients whether they have taken any risks with their health,it will inevitably
honest
individual.
the
In the scenariowhere a doctor might deny or delaylife
penalize
savingtreatment to patients on the basisof their previousbehaviour.,there would be a
incentive
for the patient to withhold information or lie. If the trust
considerable
betweendoctor and patient is not maintainedpatientsmay be unableto divulge
information
relevant
about their former lifestyle and subsequenttreatmentmay not be
the most beneficial.
Haavi Morreim (1995: 8) writes 'the physicianwho deniesmedicalcareas a penalty
for irresponsibleconduct is no longer a healerwith a fiduciary commitmentto each
but
'
doctors
If
decisions
to
enforcer
patient,
an
of social policy.
were asked make
lifestyle
in
determine
be
the
their
to
of
patients, order
about
who should allocated
it
Patients
the
the
of
relationship.
scarcemedical resources, might change very nature
be
in
doctors,
lose
to
may
weighing up the cost of their
confidence
who appear
4
treatmentagainstthat of other patientsor evenpotential patients. Sabin(1998)
by
between
have
doctors
to
acting as excellentclinicians,
choose
may
suggeststhat
doing as much as possiblefor eachpatient's health, and being responsiblecitizenswho
health
for
do
the
the
available
within
population's
should as much as possible
resources.
Many patientsmay genuinelyunderestimatethe numberof cigarettesthey smoke,or
lifestyle
idea
The
the
of
the amount of alcohol they consume.
of monitoring
George
feel
has
intrusion
individualsintroduces an unacceptable
of
a
of privacy, and
difficult
be
it
to
You".
In
is
Watching
Orwell's 1984 - "Big Brother
practice, will
judgements
homes
in
their
about
the
know what behaviour people adopt
and
privacy of
be
individuals
made
caution.
lifestyle
with
the
should
of
4ROyalCollegeof Physicians SettingPriorities in the NHS A Frameworkfor decisionmaking Royal
21
1995:
London
Collegeof Physiciansof
171
In summary,it appearsthat any policy to distribute health care,which includesthe
lifestyle,
criterion of
presentsa number of problemsin practice. Even if we acceptthat
individuals
have
some
voluntarily chosento take known risks with their health,it
difficult
determine
disadvantaged,
be
if anyone,andwhich
to
who should
seems
behaviourshould be included in the policy. In practice, can doctors really be expected
to makejudgementsabout individual lifestyleswithout destroyingthe traditional trust
doctor
/
honesty,
which underliesan effective
patient relationship?
and
172
6.2
Should rationing be implicit or explicit?
In the NHS, rationing of resourceshastraditionally beenimplicit
without guidelinesor
While
the governmentsetsconstraintson overall expenditureand
statedcriteria.
generalentitlementwithin the legal framework, the doctor determinesdecisionsabout
the allocation of resourcesbetweenindividual patients. Chris Ham (1995- 1484)
has
Britain
that
suggests
adopted an approachto rationing that is best describedas
'muddling through.' Politicians have historically deniedthat rationing in the NHS is a
reality and tend to talk of setting priorities (Bottomley 1993),rather than attemptingto
setnational guidelinesabout who shouldbe treated, and which core servicesshouldbe
provided.
'
Severalauthors have put forward convincing argumentsto support a strategyof
implicit rationing. Mechanic (1992 : 1722) is unequivocalin suggestingthat implicit
rationing offers 'the best opportunity to allocate care effectively in the context of
base,
in
knowledge
heterogeneity
American
the
population
and
uncertainty,a changing
doctors
best
in
illness.
'
He
that
placedto
and patterns of
professional
are
argues
judge which patients should receivethe availableresourceson the basisof their
individual needsand the expectedbenefitsof treatmentin eachparticular case.
Implicit rationing allows doctors to considerthe specificcircumstancesof casesand
inflexible
by
insensitive
be
discretion,
to
than
and
restricted
rather
usetheir clinical
guidelines.
Hunter (1997) has also arguedthat implicit rationing, or 'muddling through elegantly'
it
is
He
that
difficult
an
best
suggests
area.
complex
and
the
a
offers
option within
because
decisions
the
doctors
if
public will support
make rationing
advantage
decisions,which are seen,rightly or wrongly, to be clinical in characterrather than
Grand
(1996).
Le
(1995),
New
Mechanic
(1997),
Klein
(1997),
and
SeeCoast (1997), Hunter
173
political (Hunter 1995: 878). It appearsthat people havegenerallytrusted their
doctors to make decisionsbasedon the best interestsof their individual
patients.
However, this may result in a dilemmafor doctors. Doctors have a
professional
responsibilityto provide the best possiblecare for their patients,accordingto the
beneficence.
This may competewith the duty to be fair to
principle of
other patients
by
potential
patients promoting cost effective care. In order to fulfill this second
and
duty, doctors act as 'gatekeepers'to the specialistservicesasthey attemptto keep
budget
limits
the
of the practice or trust
within
-
Implicit rationing may be defendedon the groundsthat clinical discretionis valuable
becausemedical care is complex, uncertain and developing,andpatientshavedifferent
doctors
inform
In
to
priorities and needs. practice,
may prefer
patientsthat treatment
in
interests',
be
best
'not
their
rather than statethat resourcesare unavailable,
would
be
hidden
decisions
be
It
the
that
may
context of clinical management. may
within
so
discuss
having
for
doctors
to
than
this
take
to
rationing openly.
approach,rather
easier
However, since 1991 and the introduction of the purchaserprovider split, the so-called
internalmarket, rationing in the NHS hasbecomemore explicit at both micro and
flu
the
Bowen,
Child
B,
Jaymee
the
withdrawal of
and
macrolevels. The caseof
have
NICE,
from
the
the generalpublic, on
recommendationof
vaccine.,Relenza
increasing
been
has
there
awareness
in
and
coverage,
media
resulted widespread
(without
taxes).
do
NHS
raising
the
cannot everything,
amongstthe public that
be
6
that
rationing should
Severalcommentators have presentedargumentsto suggest
basedon explicit and centrally determinednational guidelines.
the
individual
taken
for
within
decisions
are
is
patients
It clear that
about treatment
Health
Department
from
and
the
of
boundariesof an increasingnumber of guidelines
1995
Maxwell
1996,
Maynard
1997,
SeeDoyal 1997, Lenaghan
174
other advisory bodies such as the UK CochraneCentre andNICE. Theseexplicit
guidelinesoffer certain advantages.National centrescanreview the availablescientific
data and inform practitioners of the most effective treatments that less
so
effectivecare
be
The
can withheld.
public will know preciselywhere they standwith regardto
future entitlementsto health care and can be involved in the debate
about what kind of
NHS
the
services
should provide. If rationing remainsimplicit and hiddenwithin
decisions,
clinical
people may be unawarethe consequences
of their behaviour.
There appearsto be somepublic sympathyfor a policy, which rations healthcareon
the basisof lifestyle. In the original rankingsfrom Oregon,which were devisedfrom
telephonesurveysand structured public meetings,a list of priorities was presented
(Dixon and Gilbert Welch 1991). Liver transplantsneededas a result of alcoholic
in
liver
695
In
the
table.
transplantsneededas a
cirrhosiswere ranked
comparison,
liver
indicating
365
that
result of
cirrhosis, with no mention of alcohol, were ranked
they were worthy of preferentialtreatment. This may reflect different attitudesto so
from
disease
'self-inflicted'
those,
other causes.
as comparedwith
which arise
called
Of course, even if public opinion appearsto sympathize with a policy for rationing
health care according to lifestyle - it does not follow that it is justifiable or morally
by
be
Public
swayed the manner of questioning, media
acceptable.
opinion can
is
There
is
no
presentation and anyway, merely a collection of subjective views.
based
thought
out views,
guaranteethat the opinions expressed are reflective of well
be
the
interviewed
For
of
information.
those
may
unaware
example,
on accurate
implementing
difficulties
such a policy.
of
pragmatic
(1999)
Ferguson
Cookson
Dolan,
This is well illustrated in a recent study.
and
in
its
investigatedthe extent to which the public changes n-ýindabout priority setting
Initially
deliberation.
discussion
for
about
healthcare following an opportunity
and
175
half of the respondents(sixty randomly chosenpatients)wantedto
give lower priority
to smokers,heavy drinkers and illegal drug users. However, after discussionmanyof
the groups no longer wished to discriminateagainstthesepeople. Their findings cast
doubt
about the stability of preferences.
some
In addition, society is madeup of a number of different groups and cultures,which are
in
is
It
pluralist character.
not obvious how one could accessthe public in order to
balanced
bias
in
favour
view and avoid a
obtain a
of the well-articulated,middle class,,
Hunter
(1995:
is
883)
if
the
that
there
or
worried well.
suggests
a risk
we move to
be
'less
the
treated,
rationing
and
consult
public
explicit
about what and who should
being
decision
further
from
the
making
articulateand marginal groups risk
excluded
process'.
Despitethe inherent problemsof public consultation,there hasbeenan increasing
in
health
the
the
care,particularly
consumersof
emphasisupon
active participation of
1997)
H.
'(D.
Dependable.
Modern.
New
NHS:
Paper,
'The
White
and
of
the recent
is
democracy
in
is
this
It
that
a
a
the establishmentof primary care groups.
argued
7
has
debate
(1998)
the
Holm
desirabledevelopment.
about rationing
suggeststhat
to
the
from
priority
in
of
process
the
setting
priority
of
principles
shifted emphasis
devise
be
it
to
simple
increasing
a
is
that
There
possible
not
will
recognition
an
setting.
be
treated
decisions
in
and
should
who
about
to
setof rational rules guide practitioners
in
Scandinavia
the
Holm
that
Rather,
be
suggests
what conditions should treated.
its
itself
debatenow focuseson the priority setting process
and transparency.
for
be
Danielsand Sabin(1997) have arguedthat there must an open process making
they
have
they
which
proposedconditions,
decisionsabout health care rationing and
Key
in
decision
legitimacy
of
fairness
elements
making.
to
and
claim would contribute
' SeeGutmann A. Thompson D. (1996) suggestthat citizens or their representativesshould continue
decisions.
acceptable
to reason together in order to reach mutually
176
the fair processwill include 'transparencyabout the groundsfor decisions;appealsto
rationalesthat all can accept as relevant to meetinghealthneedsfairly; and procedures
for revising decisionsin light of challengesto them' Daniels(2000: 1300).8 Together
theseelementsassume'accountability for reasonableness.
' The public shouldhave
for
to
the
rationales
access
rationing decisionsand if this processwere implemented
law
be
developed.
could
overtime.,case
Even those who have arguedpersuasivelyfor implicit rationing at the micro level of
including
Mechanic (1992 1713), acceptthat future rationing will
patient care,
.incorporatea 'blend of approaches.' Hunter (1997: 137) doesnot advocatethat
decisions
basis
the
should
professionals
make
about resourceson
of their preferences
'especially
alone,
when these are socially rather than clinically based.' Rather he is
be
framework
that
there
clear
should an overarching
of proceduralguidelinesto
'structure the way in which decisionsare madeand ensuregreatertransparency'
(Hunter 1997: 139). He goes on to suggest that these explicit guidelines 'would
endeavourto establisha set of generalprinciples expressing,or rather restatingsince
for
fair
NHS
the
the
they alreadyexist,
and setting standards
values and objectivesof
139).
Within
(Hunter
1997:
suchguidelines,
andconsistentadministrativeprocedures'
it would be possibleto include an open and clear statementaboutwhetherlifestyle will
be assessed
in relation to the allocation of medicalresources.
OxfordshireHealth Authority has set up a 'priorities forum' to provide adviceon
focuses
three
framework,
bases
decisions
forum
on
The
which
on an ethical
rationing.
Reynolds,
Hicks,
(Hope,
key areas:evidenceof effectiveness,equity and patient choice
discrimination
be
on
there
The
that
Crisp and Griffiths 1998).
no
should
states
group
learning
lifestyle,
factors
employment,
suchas
groundsof personaland social
' Current practice in the NHS does not always appear to meet these conditions. Ham and McIver
found
the
decisions
that
disagreements
treatment
involving
and
over
(2000) reviewed five cases
for
decision
have
did
appeals
or
an
making
process
an
explicit
health
not
authorities
responsible
procedure,
177
disability, age, race, social position, financial status,religion,
or place of abode.
In The Netherlands,a report by the GovernmentCommitteeon Choicesin Health Care
(1992: 64) has explicitly statedthat an unhealthylifestyle shouldnot be
usedas a
This
Committee
criterion.
rationing
suggestedthat everyoneshouldhaveaccessto
healthcarewhen it is needed.,regardlessof the reason. I would suggestthat the UK
governmentshould make a similar statement,so that the public will know precisely
in
future
they
terms
can
expect
what
of
entitlementto care, andwhat, if any,behaviour
in
disqualification
delay.
In addition, when decisionsare explicit, and
result
will
or
basedon publishedguidelines,there could be a systemof appealsfor thosepatients,
feel
have
been
denied
they
that
who
appropriatetreatment.
Sincethere is no explicit recognition in suchgovernmentdocumentsas 'The Patient's
Charter' or 'ne NHS Plan'that peoplewill forfeit health care,if they adopt an
behaviour
have
lifestyle,
be
their
that
to
they
they
may
change
may unaware
unhealthy
in order to qualify for the most effective health care. If sucha criterion for rationing is
introduced,people should be given the information accuratelyso that they canmake
decisionsabout their behaviour with the relevantknowledgeof future consequences.
In addition, if the NHS introduced a policy to give lower priority to thoseindividuals
help
have
it
health,
to
consideroffering more
would
who were taking risks with their
9
to thoseindividuals trying to give up unhealthyhabits.
Seechapter 5 for further discussion
178
6.3
The mechanisms of rationing
A policy for rationing health care needsto indicate
which mechanismsshouldbe
implemented.'O For example,would denial of care bejustified,
or shouldwe consider
delay, or an inferior service,for those individuals
have
taken risks? In practice,is
who
it really possibleto deny treatment to a patient who has smoked
excessivelyand
developedlung cancer?
The mechanismof denial seemsunrealistic do we really want a policy, which
ill
that
suggests
people should be turned away from the clinic or hospitaldoors?
Health care professionalscould not standby idly, refusingto offer careto an identified
personwho presentswith genuinemedicalneed. The denial of healthcareat the time
be
harsh
to
of needseems
unreasonably
and reflects a meannessof spirit, which
thankfully is not evident in society. Requiring peopleto live with the consequences
of
their actions could, in the scenarioof denyingmedicalcare,lead to considerable
death.
be
by
incurred
In
there
sufferingand even
somesituations,
may additionalcosts
delay
in treatment as the diseaseprogressesand treatmentmay becomemore
any
difficult. There may also be risks for otherswho might becomeinfecteddue to
infectious
to
person.
prolongedexposure an
It seemsunlikely that societywould accepta policy, which refusedhealthcareto those
individualswho have urgent medicalneeds,whateverthe cause. Peoplewho collapse,
Consider
in
have
other areas
or
major accidentsare not refusedmedicalcare casualty.
lost
in
the
to
is
lives.
send
There
and
sailor
tremendous
rescue
society
urge
a
of our
have
brought
because
the
they
deny
do
crisis
lifeboat.
We
sailorsrescue
not
out the
disregard
the
to
have
coast
They
choice
themselves.
a
made
voluntary
may
upon
10 SeeHarrison (1995) who suggeststhat a policy agendafor health care should focus on three
for
What
exist
by
should
mechanisms
occur?
the
What
rationing
should
which
criteria
questions:
are
Who
decisions?
implementing
should ration?
rationing
making and
179
guard's warning of severeweather and potential hazards. Nevertheless,
we would still
attempt to rescuethem if the needarose. Similarly off piste skiershave
often
disregardedwarnings of avalanchesand yet the rescue
serviceswill strive to help if the
needarises,evenwhen there is potential dangerfor the rescueteam.
While we do not deny treatment to those with urgent medical
needs,it appearsthat
somerefusalsfor lessurgent needsare tolerated. Peopleare sometimesdeniedaccess
to fertility treatment and drugs such as viagra on the NHS. Sincethesetreatmentsare
for
sometimes conditions, where there is diseaseand loss of normal function, this may
be interpreted as a denial of health care. Cochrane,Ham, Heginbothamand Smith
(1991) statethat at presentthe idea of peoplebeing deniedhealth servicesis very
foreign to most membersof the public. Theseinfluential writers also suggestthat any
down
the route of denyinghealth care hasto be understoodandultimately
progress
by
approved the public.
In the unfortunate scenario,where it is impossibleto treat everyonewho presentswith
medicalneed, and rationing of health care becomesa reality, the NHS usuallyoffers an
inferior serviceor delayedtreatment. Thesemechanismsseemto be more acceptable
less
denial
drastic
forms
The
than
they
and
elderly person
of rationing.
and yet
are
be
infarction
is
to
may transferred
who admitted casualtywith a suspectedmyocardial
to the generalmedical ward, insteadof the more specialistcoronary careunit. A
deliberatechoice can be madeto deny an expensiveand effectivetreatmentin favour
limited
because
it
be
less
though
resources.
of
may
effective,
of a cheaperoption, even
Choicesabout drug treatment can be madein a similar manner,and shouldbe
recognizedas rationing.
The use of waiting lists in a number of clinical specialtiesis widely accepted.
Anecdotal accounts suggestthat certain individuals - those who smokeor drink
180
be
low
lists.
We shouldhoweverbe
may
excessivelygiven
priority on waiting
in
in
delay
that
the
treatment is solely attributableto judgements
cautious assuming
lifestyle
Many
previous
per se.
potential patientswin haveto wait for
about
before
time,
sometimesmonths,
considerable
specialisttreatmentsuchas cardiac
liver
is
transplantation
available. Doctors might arguethat thosepatients
surgeryor
be
highest
in
the
probability
of
good
rehabilitation
will
chosen
preferenceto those
with
individualswho have increasedrisk factors, suchas a history of smokingor
alcoholism.
Any mechanismto ration health care accordingto lifestyle, including denial,delayor
dilution-,is contrary to the statedprinciples of the NHS, where it is emphasizedthat
for
health
deny
To
is
to
care
medicalcare allocated according needand needalone.
important
it
is
that
is
However,
to
illness
recognize
time
the
of need callous.
at
acute
form
is
delaying
treatment,
deliberatelyoffering a secondclassserviceor
of rationing
a
individuals
for
implementing
be
who
certain
mechanism
such
of
wary
should
andwe
determining
because
lifestyles,
haveadoptedunhealthy
of the practical problemsof
behaviour.
for
is
their
who responsible
181
6.4
Alternative
Policy Options
While it may be acceptableto ration health care accordingto lifestyle in
principle, I
havesuggestedthat this cannot be implementedwithout potential
practicalproblems.
Thereare alternativepolicy options though, which could be implemented,and may be
fairer to those involved. Peoplemight be askedto pay for treatmentat the time
of
had
if
indulged
in
they
need,
certain high-risk activities. Indeed,all car drivers are
currently expectedto pay a small contribution to their medicalcare andwill be charged
"
if
NHS
department
they
by
taken
to
Since
accordingly
are
a
the
casualty
ambulance.
insurancecompanyusually paysthis charge,peoplehavenot expressedundueconcern.
Yet only car drivers are expectedto pay this chargeand anyonewho arrivesin casualty
following an accidenton a bicycle, or at home, will not havea similar levy imposed.
This appearsto be a chargefor those individualswho chooseto travel by car.
Thereare problemswith a policy to chargeindividualsfor healthcarecosts,at the time
Such
happens
Firstly,
to
those
to
a policy
pay?
of need.
peoplewho are unable
what
hardship
insurance
disadvantage
and causepotential
people without money or
would
for the poor. This is contrary to the statedprinciples of the NHS, which is to provide
the best possiblecare for all, regardlessof the ability to pay.
Secondly,it would be essentialto identify clearly which behaviourwould be associated
If
further
in
charge
This
a
problems.
classification
present
reality
may
with charges.
for horseri'ding was imposed,it might be necessaryto distinguishbetweenthe sedate
different
There
are certainly
rider in the countryside and the cross-countrycompetitor.
degreesof risk. One person may be an occasionalsmoker,while anothermay smoke
forty a day. Are they to be treated in the sameway?
" SeeMontgomery 1998: 55. The Road Traffic Act 1988 expressly permits chargesto be made in
traffic
accidents.
road
treatment
to
after
relation
182
I
Veatch (1980: 5 1) and Le Grand (1991: 120)
suggestan alternativepolicy option,
is
which more plausible and is reflected in current practicein the United Kingdom.
Additional tax could be levied on those products,
suchas cigarettesand alcohot and
specialistsporting equipment,which are proven to be a risk to health. Tax could be
calculatedat a rate to cover the extra costs of the anticipatedfuture care. Even if
individuals
died
some
prematurelyin middle age, as is often the casefor smokers,
therebysavingmoney from long term care,the calculationsof tax
be
will
an estimate
future
of
collective costs for all smokers,rather than an estimateof the eventualcosts
for the individual.
It might be suggestedthat taxation on certain products, suchas cigarettesand
alcohol,
reflectsa valuejudgement about what constitutes'good' behaviour. We do not tax
the sportsplayer who takes risks, or the sexuallyactive personwho choosesto ignore
adviceabout safe sex. Even if we wishedto impose suchtaxes,it would be difficult in
practice. Nevertheless,the fact that it is impossibleto tax all unhealthybehaviourin a
fair manneris no reasonto refrain from doing so in a few obvious cases cigarettes,
alcohol,and fast cars. But there is a needto ensurethat prejudicesdo not become
in
evident our policies.
Individuals.,who are responsibleand make the effort to maintaina healthylifestyle, and
having
individuals
those
to
avoid unnecessaryrisks, may resent
who are more
subsidize
it
following
'Is
(1995:
Gutmann
113)
the
reckless.
question
unjust to constrain
poses
accessto medical care by making it more costly to peoplewho voluntarily take
USA,
based
insurance
healthT
In
the
their
systems,suchas
unnecessaryrisks with
it
is
health
future
to
towards
their
possible
costs,
care
wherepeople pay contributions
increasethe levy for those who adopt risky behaviour, suchas smoking,or eating
from
derived
taxation
NHS,
In
and
the
general
resources
are
excessively.
where
by
individuals,
be
from
is
placing a
raised
certain
entitlement universal, money can still
183
tax on those products, which are deemedto be a risk to health. In this way, those
individuals who partake in certain activities canbe madeto contribute
more to the
health care budget. Thesepracticesindicate that we do considerpeople
responsible
for someof their choicesabout health relatedbehaviour.
In conclusion,people should not be deniedhealth care at the time of needbecauseof
their lifestyle, If resourcesare limited and choiceshaveto be madebetweencompeting
patients,then a number of considerationsare relevant. Theseshouldinclude an
of medical need,patient choice and the predictedclinical and cost
assessment
12
lifestyle
itself
be
Previous
in
treatment.
effectivenessof
consideredas a
shouldnot
because
in
individual
have
limited
had
it
is
the
cases
many
may
options and
criterion
difficult in practice to evaluatewho is responsiblefor their lifestyle choices. It should,
however,be recognizedthat certain habits, suchas smokingand overeating,may have
for
doctors
health
this
detrimental
the
may
care
and
of
outcomes
on
clinical
affect
a
lifestyle
is
decide
that
one of the criteria to considerwhen allocatingscarce
reason
resources.
Many of us may remain concernedabout the escalatingcosts of healthcareandmay
be
known
in
to
a
feel intuitively that those who chooseto partake activitieswhich are
to
financial
People
choose
who
health
costs.
risk to
should contribute to the resulting
limited
by
indirectly
harm
health
medical
using
take risks with their
others
can
imposition
tax
The
for
a
health
of
increasing
everyone.
the costs of
care
resourcesand
health
therefore
detrimental
have
known
would
to
effect on
a
on certain products
the
financially
towards
have
to
fair,
be
contribute
that
partake
to
who
people
so
appear
health
care,
Not
require
these
behaviour.
will
people
all of
anticipatedcosts of their
be
ill,
treated
resentment
become
then
without
but those who are unlucky and
should
at the time of need.
12
Seechapter 2
184
ChapterSeven
CASE STUDIES
7.1
Should smokershave equal accessto health care alongsidenon-smokers?
7.2
Should alcoholics and non-alcoholicscompeteequallyfor liver transplantation?
7.3
Should sportsmenand women contribute to the costsof treatingtheir injuries?
7.4
If competentpatientsdo not comply with prescribedtreatment,shouldthey
forfeit future care on the NHS?
7.5
Should 'lifestyle drugs' be prescribedon the NHS?
185
7.1
Should smokers have equal access to health
care alongside non-smokers?
In May 1993, it was reported that doctors at two of the
country's biggestheart centres
were refusing to perform life savingoperationsand investigationsfor smokersýunless
they gave up the habit (Rogers 1993: 1). That sameyear, Harry Elphick, died
aged
forty-seven, having beenrefusedcardiac surgeryfollowing a heart
attack. He was
in
to
advised enrol a 'smoke-stop clinic' prior to being reassessed
for treatmentat a
later time (Butler 1999: 52). He died having given up smokingwhile
for
the
waiting
reassessment.
There are three arguments to support a surgeon's decision to delay treatment until
have
behaviour
their
patients
changed
and given up smoking. Firstly, resources are
limited and should be allocated to those patients where the best outcomes are
Underwood
(1993:
describe
Bailey
1047)
the potential risks of
predicted.
and
including
to
performing coronary artery surgery on patients who continue smoke,
higher incidence of immediate postoperative complications and increasedrisk of
it
is
failure.
is
While
possible,
reoperation sometimes
atherosclerosis and vein graft
from
take
other patientswho
more expensiveand will obviously
yet more resources
'Patients
(1993
1047)
for
Underwood
Bailey
that
treatment.
claim
:
and
are waiting
from
have
hospital
than
longer
in
nonsurgery
results
poorer
and
who smoke spend
have
have
deprives
Treating
them
never smokedor who
patientswho
smokers.
forward
is
'
This
argument
stoppedsmoking of more efficient and effective surgery.
looking and suggestswe should treat those patientswhere the best resultsare
expected.
Secondly,delayingtreatment for smokersmay be an effectiveway of persuadingthem
Ward,
behaviour.
Christopher
harmful
a consultantcardiologist,who
to give up this
186
promoted a policy that smokersshould not be treated until they had stoppedsmoking,
justified this approachby stating that 'It's a good way to persuadethem to
"
give up.
Indeed the British Medical Association issueda pressstatement,which statedthat 'For
someconditions giving up smoking can be the best immediatetreatment12
Thirdly, it may be suggestedthat the illness and increasedrisks of surgeryfor smokers
Smokers
by
have,
their own choicesto smoke,contributedto their
are self-inflicted.
illnessand they do not deserveto be treated as quickly as non-smokers they must live
behaviour.
This
their
the
consequencesof
argumentsuggeststhat smokersshould
with
be
because
behaviour.
their
of
past
not given priority
However, there are problemswith thesethree suggestions,Firstly, cost effectiveness
for
distribution
is
the
the
the
of medical
sole criterion
and
efficient use of resources not
for
treatment
When
the
non-smoker
or
patient
smoker
assessing
we are
resources.
be
lower
increased
successrates shouldnot always an
risks or
and possiblesurgery,
indication to withhold or delay surgeryif there are still net benefitsfor the particular
but
there
from
less
than
have
the
to
Smokers
non-smokers,
surgery
gain
may
patient.
is
based
(1993:
1049)
that
on
Higgs
science
be
medical
comments
somegain.
will still
follows
It
that
will
smokers
some
more.
no
perhaps
probability - good guessesand
defy probability and may do well following surgery.
incidence
increase
the
complications
of
factors,
Smoking is one of many risk
which will
be
increased
there
is
that
will
But
guarantee
a
not
smoking
of coronary surgery.
fit,
be
young
individuals
physically
may
smoke
who
some
and
morbidity,
and
mortality
the
outcomes
predicted
on
too
decisions
emphasis
If
much
lucky.
made
with
are
and
incidence
higher
of
factors,
known
have
a
and
risk
treatment,
who
patients,
of
Times
Sunday
The
1 Cited in Rogers L. 'Hospitals refuse to operate on heart patients who smokc'
May 23,1993: 1
1994
13
January
Press
release'
2 British Medical Association 'Equal Accessto NHS treatment
Cited in Dawson (1994)
187
complicationsincluding women, the elderly, those who are obeseor haveexisting
diseasesuch as diabetes,will be given low priority. This
appearsto discriminate
againstcertain people on the basisof factors, which are not relevantto medicalneed
be
and would
contrary to the current aims of the NHS, to promote equalityof access
to services.
Secondly,will the threat of delayedtreatmentreally persuadepeopleto give up
is
little empirical researchto suggestthat suchan approachwill be
There
smoking?
help
effective and actually
peopleto changetheir smokingbehaviourin the long term.
As statedearlier, if the fear of lung cancerand heart diseasehasnot deterredthe
it
delayed
then
that
the
threat
treatmentwill now be
smoker,
seemsunlikely
of
In
effective. addition, we might object to suchan approachbecauseit is coercive,with
'
loss
individual
the associated
of
choice.
Thirdly, is it fair to penalize smokers for their past behaviour? Do they really deserve
to be given low priority on the waiting list becausethey have contributed to their need
for medical care? Certainly they may have acted unwisely or self indulgently but they
have now developed a life threatening disease. Is it justifiable to inflict further
for
individual
for
both
their
the
perhaps
and
potential anxiety and possible suffering,
family / ftiends, by delaying treatment?
have
Certainly if smokershad no choice about whether to smokeor not, and could not
behavedother than they did, they do not deservedelayedor secondrate treatment.
habit.
difficult
it
the
find
to
but
give up
Somesmokersmay have somecontrol,
still
limited
have
no control or
Doctors will not be able to distinguishwhether smokers
behaviour.
their
control over
Coercion has been discussedin Chapter 5, section 4.
188
Recent evidencesuggeststhat many people have little
or no choiceabouttheir
behaviour.
The Royal College of Physiciansof London (2000: 87)
smoking
emphasizesthat cigarette smoking shouldbe understoodfirst and foremost as a
manifestationof nicotine addiction. This report, 'Nicotine Addiction in Britain',
presentsconvincing data to support their claims. When peopletry to stop smoking,
the rates and patterns of relapseare similar to heroin.,cocaineand alcohol.
Approximately 25% of people will relapsewithin 2 daysof their last
cigaretteand
approximately50% within one week (Royal College of Physicians2000: 97). Even
with the onset of certain life threateningdiseases,suchas lung canceror heart attacks,
the majority of smokersare unableto stop smokingcompletelyin the year after
diagnosis. Despite medical and nursing support, and evenwhen the smokerappears
determinedto stop smoking,thesefigures remainconstant.
But what does it meanto saythat the smokeris addictedto nicotine?4 The Royal
CoRegeof Physicians (2000.83) uses the term to describe the 'situation in which a
drug or stimulushasunreasonablycometo control behaviour.' According to Goodin
(1989) the test of addiction is not whether it is impossibleto give up the behaviour,but
for
but
have
difficulty
Many
the
some
given up smoking,
people
rather
of withdrawal.
be
it
inherited
traits,
those
may
people,perhaps
with addictive personalitiesor certain
is
desire
If
those
impossible
that
to
the
to
even
so
strong
smoke
give up.
virtually
5
temptation
'reasonable'
the
'normal'
we
cannot
resist
self-control
and
peoplewith
,
do
have
People
for
impossible
be
it
somepeople.
shouldrecognizethat might virtually
be
'No'
for
but
may more
the capacityto say 'No' to the next cigarette,
some,saying
difficult. This may be reflected in the idea that manypeoplewould rather not smoke
difficult
it
find
to give up
they
and yet
very
4 According to the World Health Organisation, drug addiction is a psychic or physical stageresulting
behavioural
by
and
drug,
living
from the interaction between a
characterised
and
organism and a
its
desire
avoid
and/or
include
to
effect
that
experience
a
compulsive
always
other responses
discomfort of its absence. Cited in Oommen (2000)
5There is increasing evidence that there is a physical link betweenparticular receptorsin the brain
behaviour
to
or
repetitive
tend
compulsive
generate
which
189
Smoking prevalencein the United Kingdom has
stabilizedat one in four of the adult
population with much higher levels in the deprived sectionsof society. Although
two
thirds of smokerswant to quit and about a third try each
in
year, the last ten years,
long-term cessationrates amongstmiddle-aged
smokershaveaveragedaround2% per
(Royal
College of Physicians2000: 122). The report
year
concludesthat once
dependenceis established,the majority of smokers
will continueto smokefor nearly
40 years.
It is wrong to penalizesmokersfor behaviour.,which is very difficult to
control,
particularly sincethe vast majority of people, over 80%, who becomeregular smokers,
start smoking as young adolescentsin the United Kingdom (Royal Collegeof
Physicians2000: 101). If there is a voluntary choiceto smokeor not, it will be at the
point when you begin smoking, and the data would suggestthat this is often at a
relatively young and immature age, often under the age of fifteen. Notably, this is
beforeyou are legaffy consideredto be mature enoughto buy cigarettesin this
country. The report (page 101) states'Decisionsto smokemadein the earlyteenscan
be consolidatedinto addictive behaviourbefore the smokerreachesmaturity1)
HenceProfessorJohn Britton, Chairmanof the report andProfessorof Respiratory
Medicine at the University of Nottingham, states'We would like to seehealth
just
be
disorder
to
treated
that
professionalsand the public accept smokingas a
needs
like any other disease.6 Nicotine addiction shouldbe seenas a major medicaland
in
If
be
it
socialproblem and should treated as such. nicotine addictionresults a
be
follows
it
it
that
then
medicalneed,
should treatedwith nicotine replacement
behavioural
bupropion,
interventions
therapy and other
and
suchas the antidepressant,
funded
NHSthe
on
support groups,
Cited in Kmictowicz (2000)
190
Even if we acceptthat smoking shouldbe treated
as nicotine addictionand as a disease
in itself, somepeople may still ask whether it
be
should treated on the NHS. The NHS
provides treatment to meet 'medical needs'but doesnot claim to treat all disease.
Sincethe NHS does not alwaystreat impotence,or infertility,
which may be the result
disease,
of
we cannot assumethat the NHS will treat nicotine addiction. I havealready
suggestedthat health care resourcesare scarceandthere will obviouslybe competing
demandsfor NHS funds, and preferencemay be given to life savingtreatments
and
acute services. Currently, nicotine replacementtherapyis not universallyavailableon
the NHS and only certain preparationsare availablein someareas.
However, the NHS does recognize the importance of prevention of diseaseand has set
immediate
out plans and
priorities in the recentlypublished'National Service
Frwneworkfor
Coronary Heart Disease' (Department of Health 2000). Reducing the
prevalenceof smoking, and the successfultreatmentof nicotine addiction,could
disease,
is
in
heart
biggest
death
the
coronary
effectively reduce
which one of
causesof
7
this country. Hence, the Royal College of Physicians(2000: 188),,Moxham (2000),
be
(2000)
Britton
therapy
that
should widely
nicotine replacement
and
suggest
for
it
is
treatment
NHS
a rational and cost effective
availableon
prescription, since
'
therapy
Clinical
the
that
trials
replacement
nicotine
of
use
confirm
nicotine addiction.
increase
inhalators
the
of
of
success
rate
significantly
will
patches,
spray
or
gum,
1999)9.
May
Review
(Cochrane
breaking
their
addiction
smokers
' More than 1.4 million people suffer from angina; 300,000 have heart attacks every year and more
Secretary
by
A.
'Foreward
the
Qvfilburn
of
than 110,000 die of heart problems in England every year
2
2000:
Disease
Heart
Coronary
Service
Frameworkfor
State' In Department of Health National
8 The Royal College of Physicians (2000) suggestthat nicotine replacementtherapy costsbetween
treatment
is
to
This
medical
other
L212 and E873 per year of life saved (1996 prices).
comparable
available on the NHS.
9 Silagy C. Mant D. Fowler G. Lancaster T. Nicotine replacement therapyfor smoking cessation
in
Royal
Cited
Software
Update
Oxford
(Cochrane review) In: The Cochrane Library, Issue 2,1999.
College of Physicians 2000: 143
191
In essence,smokersdo not deserveto forfeit health care on the basisof their lifestyle,
becausemany are suffering from an addiction. Behaviourthat is the result of addiction
is unfortunate but not blameworthy, sinceit is not within the control of the victims
it
is
is
Further,
this
acquired.
addiction
once
often acquiredwhile the personis still
immature, and may have unrealistic expectationsthat they will be ableto control the
behaviour. We may therefore excusethis behaviour,and we shouldoffer support
health
follows
It
that
care professionalsshouldtreat smokers'addiction
accordingly.
further
for
future
disease
the
to
try
and
expensivemedicalcare.
prevent
need
and
Reducing smoking will be an effective way to improve the healthof the nation and
NHS.
the
the
acute
expenditureon
could reduce
but
focus
the
In addition, health care professionalsshouldnot
smoker,
exclusivelyon
failure
be
fact
of public
that people still smokecould viewed as
recognizethat the
healthcampaigns(Persuad1995). It follows that healtheducation,stricter
ban
on
the
complete
a
and
of
cigarettes
sales
enforcementof regulationscontrolling
involved.
the
be
are
young
where
particularly
priority,
a
smoking advertising should
Warningson tobacco products should also emphasizetheir addictivenature,which
disease
heart
distant
or
the
than
cancer
of
risk
be
to
people
may more relevant young
in later life.
192
7.2
Should alcoholics and non-alcoholics
compete equally for liver
transplantation?
The question of whether smokersshould have equal
accessalongsidenon-smokersfor
treatment raisesdifferent issuesfrom those of whether alcoholicsand non-alcoholics
should competeequally for liver transplantation. More people,including smokers,
be
if
treated
the NHS economicbudget and staffing levelswere increased.
could
However, liver transplantationinvolves the use of a physicallyscarceorgan there is
a
finite number of livers for transplantation,and there are not enoughlivers to
meet
demand.
Thus choiceshave to be madeabout which patientis given the
current
functioning
liver, while others are deniedtreatment,which could
chanceof a
lives.
their
potentially save
The circumstancesof liver transplantationalso differ from those of other fife saving
therapiessuchas dialysis and kidney transplantation. Patientswho haveend stage
failure
be
dialysis
for
kidney
treated
they
transplantation,
renal
can
on
while
wait
for
liver
disease
In
sometimes a number of years. contrast,patientswith end stage
win
die without the liver transplantation,becausethere is no alternativereplacement
therapyfor failed liver function.
In view of the dire and absolutescarcity of donor livers, Moss and Siegler(1991)
for
to
hold
it
is
fair
their
allocate
and
choices,
that
to
people responsible
suggest
donatedlivers on the basisof the recipient's previous choicesandbehaviour. They
lower
be
disease,
liver
develop
should given
end stage
proposethat alcoholics,who
fault
failure
liver
develop
through
list
of
no
than
the
who
others
priority on
waiting
illness
disease
from
failure,
or
congenital
their own. Hence patientswho developliver
disease
'liver
from
be
distinguished
results
those
whose
to
unrelated alcohol, should
1296).
1991:
Siegler
(Moss
for
from failure to obtain treatment
and
alcoholism'
193
If we simply cannot treat all that are in need,Moss
and Siegler(1991) suggestthat it is
fair to discriminateon the basisof former lifestyle
and alcoholismbecausethe liver
failure could have beenpreventedif individuals had
soughttreatmentand changedtheir
behaviour. Moss and Siegler(1991: 1297)
are not suggestingthat alcoholicsshouldbe
held responsiblefor their diseaseas such,but that they
shouldbe held responsiblefor
not seekingtreatment once their condition is diagnosed,so that the complications
and
subsequentliver diseasecould be prevented. Theseare not valuejudgementsaboutthe
different
lives,,but rather Moss and Sieglerproposethat
worth of
peopleshouldbe
held responsiblefor their 'personal effort. "
Moss and Siegler (1991: 1296) state that 'Although a first-come, first-served
approach
has been suggested to provideeach patient with an
equal chance, we believe it is fairer
to give the child dying of biliary artresia an opportunity for afirst normal liver' than it
is to give an alcoholic who was born with a normal liver a second one.
Glannon (1998: 46) makes a similar claim to that of Moss and Siegler. He proposes
that it is fair 'to give lower priority to alcoholicsif they havebut fail to exercise
control over the eventsthat lead to their diseaseand liver failure, andif non- alcoholics
"0
liver
failure
do
Glannon
justifies
by
this
this
with
exercise
control.
approach arguing
that people have sufficient control over their choices,actionsandthe consequences
to
be partly responsiblefor the resulting disease.Accordingly, the alcoholichasa weaker
fault
disease
liver
through
to
the
than
no
of
claim receive a new
someonewho acquires
his / her own. Glannnonrecognizesthat certainfactors, suchasgeneticmakeupand/
but
developing
individual
family
these
to
the
alcoholism,
or
upbringing, may predispose
10In this statement there is the recognition that some non-alcoholics have contributed to the
development of their liver failure by their choices and behaviour. For example, drug addicts who
failure.
liver
life
in
threatening
develop
hepatitis
B,
share needles may
which may result severeand
These patients might also be given lower priority than patients who develop liver failure through no
fault of their own, becausethey are partly responsible for their diseaseand subsequentmedical need.
194
factors do not compel the individual to drink. Peopleare
stiff partly responsiblefor
their alcoholism and subsequentmedical needfor scarceresources.
Sincechoiceshaveto be made about which personis treated, and perhaps
more
importantly which person is not treated, there is a situation of inequality. Finite
do
resources
not permit sin-filartreatmentfor all casesof similarmedicalneed
medical
in the scenarioof liver transplantation. Allocating a liver for an alcoholicmay result in
the death of a competing candidate,whose Everfailure was wholly beyondtheir
control. In this scenarioof absolutescarcity,it may be fair to includepersonal
responsibilityas one of the relevant criteria in decisionsabout who shouldbe treated,
be
treated.
should
not
andwho
While acceptingthat difficult choiceshaveto be madebetweenpatientswho needliver
transplantation,there are three problemswith this proposal. Firstly, are alcoholics
Secondly,
for
their
condition, and subsequentmedicalneeds?
really partly responsible
in practice, is it possibleto assessthe 'personaleffort' that individualshavemadeto
behaviour?
Finally,
their
medicalresourcesare not usuallyallocatedaccording
change
introduce
Why
this
behaviour
to the worth and past
should
we
patients.
of potential
for
livers
donated
in
transplantation?
the
allocation of
criterion
If we acceptthat alcoholismhas a physiologicaland/ or geneticcomponentandmay
have
limited
their
over
control
it
be viewed as a disease, would seemthat peoplemight
It
drinking.
might
less
drinking,
those
than
excessive
avoid
who
and
excessive
them
treat
for
and
their
needs
medical
thereforebe unfair to hold alcoholicsresponsible
differently from other people who have liver disease.
know
that
people
is
we
unless
We should not acceptthat alcoholism a moral vice,
behaviour.
drinking
their
about
do
make well-informed, voluntary choices
really
195
Peoplewill be strongly influencedby cultural and contextualforces,
limit
their
which
personalchoices. Only the very strong, or highly motivated,may be ableto resistthe
pressuresof social groups, role models and the environment. This impliesthat while
is
lack
restraint praiseworthy,
of restraint is not necessarilyblameworthy.
Alternatively, alcoholicsmay be viewed as neither sick, nor bad,but as
peoplewho
have developeda drinking problem through a learnedhabitualbehaviour. Ratherlike
the compulsivegambler, or smoker,the alcoholic may havebeenunduly influencedby
factors.
Personalresponsibilityfor healthandillnessis a
social and psychological
degree.
factors
be
Certain
matter of
can presentedto wholly, or partly, excusea
personfrom responsibility:there may be a family history of alcoholismand a genetic
predispositiontowards addictive behaviour. Further, manypeoplestart drinking at a
before
fully
Like
the
they
smokers,
understand risks of alcohol addiction.
young age,
in
drink
be
believe
to
that
they
now and will
able give up the
adolescentsmay
can
future, before dependenceand addiction becomea reality. It will be difficult to assess
the affects of thesefactors and the extent to which they underminecontrol and
responsibility.
Secondly,in responseto the proposal by Moss and Siegler,I would askwhetherwe
doctors,
Can
in
'personal
really
else,
anyone
or
practice?
effort'
really can assess
Moss
habits?
drinking
has
their
know how much effort anotherperson
madeto change
for
held
be
the
responsible
(1991:
Siegler
1297)
proposethat alcoholicsshould
and
their
in
the
of
to
complications
treatment
to
order prevent
seek
personaleffort needed
drinking
have
deny
and
initially
problem
they
that
a
Yet
many alcoholics
condition.
is
it
behaviour
once
impossible
this
it
find
to
compulsive
control
may
virtually
ongoing
it
to
with
find
alcohol
up
give
Other
relatively easy
people may
established.
judgements
doctors
for
to
accurate
impossible
be
make
It
support and treatment. will
It
addiction.
to
alcohol
by
overcome
about the amount of effort required an individual
196
potentially placesthe doctor in a new role
lifestyle
that
judge
Of
rather than a
clinician that treats the patient to the best of his or her ability. In
addition, the notion
of trying to determineeffort and moral strengthof character
would involve highly
intrusive investigationsand an unacceptableinvasion
of personalprivacy.
Thirdly, medical resourcesare not allocated
elsewhereaccordingto judgementsabout
the moral worth or personalcharacteristicsof other potential
patients. The car driver
who recklesslydrives too fast and causesan accidentis not deniedintensivecare
treatment. Criminals who deliberatelyharm othersin violent incidents
are still offered
medicalcare accordingto need. Alcoholics may havebeenunwise,weak willed, and
indulgent,
but they haveusually harmedthemselvesmore than
self
others. Why should
alcoholicsbe treated differently from other groups of peoplewho behavein
undesirableways?
The scarcity of donatedlivers will meanthat somepatientsdie becauseit win not be
possibleto treat everyonewho needstransplantation. Even so, it is not fair to penalize
alcoholicson the basisof their personalbehaviourand strengthof character,becauseit
be
impossible
to makejudgementsabout personaleffort andmoral worth in a
would
fair and acceptableway. Doctors havethe expertiseto makeclinical decisions,but
they are not educatedto makejudgementsabout the characterand personalityof their
patients.
Decisionsabout which patient shouldbe treatedwith liver transplantationshouldbe
basedon other criteria, such asthe predicted outcomesof treatment,and clinical
for
to
been
it
has
Until
cirrhosis
alcoholic
effectiveness.
unusual patientswith
recently,
lower
than
liver
Alcoholics
non-alcoholics
transplantation.
priority
were given
receive
becauseof the medical argumentthat the survival rate of the former was lower than
following
to
that of the latter. In addition, the alcoholic might succumb alcohol abuse
197
transplantation,which could causenoncomplianceand potential complications. It
was
be
that
argued
scarceresourcesshould usedto give the best resultsandtherefore
alcoholics should not competeequally for liver transplantation.
However, recent evidencesuggeststhat this argumentis no longer basedon accurate
information. Bird, O'Grady, Harvey, CalneandWilliams (1990) havereviewedthe
outcomesamongpatientswith alcoholic liver disease,who had receiveda liver
transplantover a period of nine years. They showedthat the rate of survivaland
liver
transplantationfor alcoholiccirrhosiswere
patients
of
rehabilitation
undergoing
in
asgood as patientswith cirrhosis of other aetiologies. Lucey et al (1992) also
demonstratedthat the survival rate for those with alcoholicliver diseasedid not differ
from that observedin non-alcoholic recipients.
Cohn and Benjamin (1991: 1300) write that the suggestionthat alcoholicsshouldnot
be treatedbecauseof poor outcomes'could serveas a good reasonto exclude
having
if
it
a
were an equallygood reasonto excludeother groups
alcoholicsonly
low
'
bad
Yet
survival
patientswith existing cancerand
or worse.
prognosisequally
it
is
to
predicted
on
therefore
alcoholics
treated
exclude
unfair
and
rates are sometimes
outcomesalone.
lower
have
substantially
Some patients, with or without, a history of alcoholism, may
illness,
to
following
psychiatric
transplantation,
related
predicted survival rates
If
the
disease,
state.
nutritional
poor
a
or
coexisting neurological and cardiovascular
is
it
these
who
patients
then
increase
is
the probability of successful outcomes,
aim to
based
is
This
on
argument
low
se.
than
per
be
alcoholics
priority rather
given
should
future outcomes rather than past behaviour, desert or any assessmentof personal
that
suggest
both
arguments
medical
that
and
I
ethical
therefore
conclude
effort.
alcoholics and non-alcoholics
liver
for
transplantation.
should compete equally
198
7.3
Should sportsmen and women contribute to the
costsof treating their
injuries?
The smoker and the alcoholic alreadycontribute significantlyto their health
carecosts
by taxation on cigarettesand alcohol. In both thesecasesthere is doubt abouthow
much personalcontrol the individual can exerciseover their behaviourandyet they pay
considerablesumsof moneyto the government. This taxation canbe hypothecatedto
fund the NHS, in order to pay for the increasedcoststhat smokersand alcoholics,
supposedlygenerate.
In contrast, sportsmenand women, who knowingly take risks with their health,arenot
future
increased
to
their
to
medicalcosts. Unlike smokersand
made contribute
be
does
there
to
appear
a strong elementof personalcontrol, asto whether
alcoholics,
the adult choosesto partake in sports suchas rugby, horseriding, motor racingor
boxing. If people partake in suchdangeroussports,knowing andunderstandingthe
health
be
their
involved,
to
to
they
subsequent
required contribute
should
possiblerisks
Should
those
injured?
if
those
make
and
who
they
enjoy
watching,
who
are
carecosts,
health
future
the
the
to
of
costs
care
these
through
sports, also contribute
money
participants?
by
fairly
those
taxing
health
distribute
the costsof
It would be possibleto
caremore
imposed
be
on
For
tax
dangerous
in
could
a
example,
sports.
peoplewho partake
imposed
be
those
insurance
upon
could
schemes
compulsory
sporting equipmentand
or
riding
country
in
cross
ski-ing,
who choseto partake certain activities suchas
additional
for
receive
would
and
NHS
everyone,
would still provide care
rugby. The
dangerous
in
sports.
take
to
part
have
funding to treat those who
voluntarily chosen
the
time
of
treatment
at
The suggestionhere is not to refuse sportsmenand women
199
but
need,
rather to ensurethat they contribute to the costsof healthcare
resultingfrom
risks voluntarily incurred.
Le Grand (1991: 124) has proposeda systemwhere health
carecostsare met in two
sorts of ways, correspondingto whether the costsresult from factorswithin the
control of the individual, or not. He writes that where peoplesufferill healthasa
factors
beyond their control 'they shouldnot suffer lossesin
result of
consequence;
hence,they should havetreatment free at the point of useand financedby the
'
he
In
community.
contrast, statesthat 'if it were establishedthat someactivities(such
did
health
smoking),
as
creategreater
risks than others,then a specialtax shouldbe
levied on those activities, at a level sufficientto generateenoughrevenueto financethe
'
(Le
Grand
1991:
treatment
123).
costs.
I-M'Era
Thereis an assumptionhere that smokingis voluntarily adoptedandI havealready
discussedthe addictive nature of nicotinel,which indicatesthat somepeoplehave
limited control over this behaviour. However in the scenarioof adultschoosingto
driven
it
is
in
dangerous
that
the
partake
sports, seems
choice generallynot coercedor
by physiologicalneeds. (There may be rare situationswherepeoplearepersuadedinto
taking risks by the attraction of money or star status,but the individualcan still makea
")
choice.
Nevertheless,there are someproblemswith the proposalthat sportsmenandwomen
dangerous
Many
health
these
are
sports
their
of
the
to
care.
costs of
shouldcontribute
benefits:
for
the
of
sense
both
their
exercise,
by
promoted,
governmentand schools,
have
a
Both
for
audience
and
being
participants
the
participants.
well
and enjoyment
thrill
in
the
overcoming
of
fun,
with
part
possibly associated
senseof excitementand
jump
or
the
having
parachute
The
known
completed
the
at
satisfaction
of
sense
risks.
3
Section
5,
Chapter
in
Persuasion and the ability to make choices has been discussed
200
cross-country course is probably related to the senseof achievementand relief at
having avoided injury.
Sport and exerciseare generallyviewed asbeneficialto health. While
somesports
boxing
known
to be especiallyrisky, there are obviousbenefits
and riding are
suchas
to the majority of participants,who will be fitter and healthierthan peoplewho do not
take any exercise.
How will we draw the line betweendangeroussportsandthosedeemedto be safe?
All sports entail risks: joggers can damagetheir joints, peoplewho play football
experiencerough tackles, and evencricket playerscanbe hit with the ball. Which
be
be
for
health
benefits?
Why should
taxed
their
promoted
sportswill
and which will
boxers and rugby playersbe singledout for discrimination,while joggers and cricket
incurring
to
their
penaltiesor costs
chosensport without
playersare allowed pursue
for subsequenthealth care? How dangerousdoesan activity haveto be beforewe are
justified in imposing a tax to ensurethat participantscontributeto future healthcare
costs?
Further we all take some risks with our health. McLachlan (1995 - 210) suggeststhat
If
health
future
for
be
people
care.
their
to
related
sex
pay
asked
non-virgins might
be
they
larger
in
should
to
drive
models,
safer
and
to
preference
cars,
small
choose
holidays
People
injury?
take
future
to
the
to
costs of possible
required contribute
in
to
different
preference
risks
involve
to
environmental
exposure
abroadlwhich may
Any
health
for
care?
have
related
Should
home.
to
they
subsequent
pay
stayingat
be
distinctions,
based
might
impose
taxes
such
to
on
system,which attempted
to
and
scrutiny
object
likely
the
it
that
public
would
In
unworkable. addition, seems
integral
be
to
the
lives,
would
which
intrusive
their
private
monitoring of
ongoing
implementationof suchtaxation.
201
Le Grand (199 1) suggeststhat the governmentshoulddiscriminate
againstall
groups
of risk takers, but in his writing he appearsto focus mainly on smokers. I would
it
is
feasible
that
to identify and tax everyone,who takesrisks with their
suggest
not
health,becausewe all take risks in different ways: driving the
car, eatingtoo much,
living in a city, or indeedtaking insufficient exercise.
However it would be possibleto selectcertain dangeroussportsfor taxation, evenif it
feasible,
not
or right, to tax all sporting activity, We would haveto be ableto
were
justify the distinctions that we made,and ensurethat our judgementswere not based
inappropriate
on
values and prejudices. We acceptthat the police placetraffic speed
ignoring
do
checksand camerason someroads7while
others,andwe not think that
this is unfair. Where the sporting risk is statisticallyproven, andwe canimposea
because
insurance
it
is
justifiable
do
'relevant'
I
to
taxation
or
so. say
scheme,
relevant
helmets,
to
taxation
or
onto safety equipment, such as cycle
put
it would seemwrong
Rather
discourage
hats,
their
we should place a tax on the
use.
riding
which might
in
hang
that
to
participants contributed,
ensure
order
glider
or
pass,
racing car, ski-ing
to the costs of their future care, without reducing their personal safety.
In essence,it appearsthat the benefitsof sport for the majority usuallyoutweighthe
Sportsmen
the
health
that
suffer.
will
minority
problems
possible
and
risks
potential
because
the
but
these
of
take
to
risks
choose
andwomen are aware of the risks,
hope
they
injured
that
become
are
do
They
to
will
benefits.
and
not choose
potential
lucky. It therefore seemsinappropriateto imposea tax on most sportingactivities,
in
However,
being
for
the
health
community.
improve
well
and
which will generally
insurance
scheme
taxation
or
be
it
to
principle, would not wrong impose a compulsory
health.
to
is
risk
proven
there
and
those
serious
a
on
sports, where
202
7.4
If competent patients do not comply with prescribed treatment.
should
)
they forfeit future medical care on the NHS?
There are a number of patientswho do not comply with prescribedtreatment. For
example,a smoker may refuseto attend the smokingcessationclinic; a transplant
immunodrugs
take
the
patient may not
suppressive
necessaryto preventrejection;and
the obesepatient may refuseto diet and exercise. In theseexamples,there are
degrees
of personalresponsibility. Nevertheless,if patientschoose
obviously various
forfeit
future relatedcare?
to
the
treatment,
they
prescribed
not comply with
should
Initially, I will considerthe casefor giving preferenceto the compliant,ratherthan to
those patientswho adverselyaffect the outcomesof medicalcare,by their choicesand
behaviour. Peoplewho continueto smokewill significantlyincreasethe potential
hospital
stay
complicationsof surgery and consequentlymay require a prolonged
(Underwood and Bailey 1993: 1047). This will haveimplicationsfor other patients,
both smokersand non-smokers,who will haveto wait longer for their surgery,
to
It
dire
therefore
potential
expect
reasonable
seems
consequences.
sometimeswith
hospital
to
to
for
admission.
to
prior
smoking
give
up
attempt
patients cardiac surgery
If patientsrefuseto co-operatewith this medicaladvice,andwill not attendsmoking
to
12
delay
people
fair
it
is
treatment,
priority
their
give
to
and
then
cessationclinics,
incidence
lower
of
from
benefit
the
with
surgery,
who are expectedto obtain maximum
complications.
increase
the
hip
risks
diet
to
will
surgery,
to
Similarly, obesepatients,who refuse
prior
prolonged
They
a
require
also
long-term
may
immediate
complications.
and
of
is
It
therefore
for
delaying
treatment others.
hospital stay, thereby 'blocking' beds and
Q
cessation
smoking
to
specialist
Authorities
set up
12The government has made it a priority for Health
Heart
Coronary
Frameworkfor
Service
National
Health
Department
2001
April
by
of
clinics'
Disease 2000: 19)
203
justifiable to give priority to those compliant patients
who will probablymakea faster
recovery, so that more patients canbe treated.
If transplant patients do not take their immuno-suppressive
drugs and subsequently
reject their transplant, shouldthey be offered a seconddonatedorgan? Is it not then
fair to offer scarceorgansto those patientswho will comply with treatmentin
order to
best
the
maximize
possibleoutcomesand the best use of limited resources?In essence,
it seemswrong to give liver transplantsto patients,who havedemonstratedthat they
will not co-operatewith prescribedtreatmentand will placethe transplantat risk.
It is important to recognizethat the decisionnot to give priority to thosepatients,who
illness
for
is
based
to
their
treatment,
contribute
and need ongoing medical
not
on the
desert.
in
it
is
decision
Rather
these
of
cases, a
notion of punishmentor an assessment
to maximizethe use of scarceresourcesand promote the best outcomesfor the
majority of patients.
Even so, I have someconcernsabout this proposal,andwish to considerthe case
doctors
for
difficult
be
it
to
Firstly,
to
the
may
compliant.
againstgiving preference
doctors
it
treatment
and places
prescribed
with
complying
assesswhether patients are
in the position ofjudge and managerof resources,rather than asprofessionals,who
the
have
Secondly,
for
whether
about
best
do
concerns
may
their
we
patients.
will
is
treatment
really makinga
individual who fails to comply with advice and prescribed
how
difficult
is
could
It
to
decision.
anyone
informed
understand
voluntary and
transplant.
drugs
their
immuno-suppressive
risk
and
take
to
sensiblychoosenot
or evena psychological
Perhapssuch a patient has somedeepmisunderstandings
for
their
individual
hold
the
responsible
illness. In such a scenario.,we would not
treatment.
medical
behaviour and might try to offer support, and ongoing
204
Alternatively, the patient may be young and / or immatureand in
somecases,it may be
hold
for
to
them
responsible their behaviour. In a controversialcase,a dentist
wrong
refusedto treat two children agednine and five, becausehe felt that the treatmentwas
little
if
dietary
habitswere poor and showedno signsof
the
value
children's
of
improving. The British Dental Association supportedthe dentist's fight to 'deregister'
did
look
(Bunting
their
teeth
1994:3). The Chief Executiveof
not
who
after
patients
the Association statedthat 'Patients do havethat responsibilityto look after their own
(Pallot
Fletcher
1994:
6).
it
However,
and
mouths'
seemswrong to hold suchyoung
for
diet
their
poor
childrenresponsible
and excessivesweeteating,when parents
influence
behaviour.
denying
have
By
their
the children
a powerful
over
should still
treatmentand dental education,the dentist appearsto be harmingvulnerablepeople,
if
decisions.
Even
long-term
their
to
the
of
consequences
who are unable understand
the intention was to persuadethe parentsto educateand protect their children,
the
treatment
young.
affect
adversely
may
withdrawing
is
identifiable
difficult
be
treat
it
to refuseto
Finally, in reality may
patientwho
an
bright
Crowfeather,
Ernie
Consider
the
a
treatment,
of
case
alreadyundergoing
therapy
Indian,
thirty
American
replacement
on
renal
months
who spent
charmingpart
He
missed
medication,
dialysis
both
refused
transplantation.
regularly
and
undergoing
doctors
The
drugs
both
and alcohol.
treatment sessionsand was preoccupiedwith
to
treatment
or
to
whether
involved in the case,repeatedlydiscussedwhether continue
In
death.
his
in
inevitably
practice,
knowing
result
this
his
that
would
terminate care
life-supporting
treatment
further
Ernie
refused
their discussionswere academic,since
hospital.
the
deliberately
with
having
contact
29,
avoided
he
died
at the age of
and
have
literally
never
they
that
in
his
would
treatment stated
The doctors involved
The
effort.
foreign
their
and
it
to
purpose
because
was
withdrawn treatment,
psychiatrist
the
turn
to
off
have
the
courage
not
suggestedthat physicianswould
be
the
right
this
that
might
he
in
hospital
suggested
Ernie
while
and
was
machinewhile
205
decision,it would be difficult and distressingto explain
decision
(Fox and
sucha
Swazey 1978).
Nevertheless, in casesof dire scarcity, it may be right to give priority to those patients
wherýethe predicted outcomesof treatmentare favourable. Whenresourcesare scarce
and we are unableto treat everyone,who needstreatment,it is right to useresources
in the most efficient way possible. If patientsdo not consentto the whole treatment
drugs
diet,
it
in
to
then
package,and refuse comply with prescribed
or
may result
blocked beds, or the inefficient use of limited resources. It doesthereforeseemfair to
benefit
the
to
those
maximum
patients,who will co-operateand obtain
give priority
from treatment.
206
7.5
Should 'lifestyle drugs' be prescribed
on the NHS?
Lifestyle drugs are used to improve the quality lif
of e, rather than alleviatingor curing
diseaseor injury and are sometimesprescribedfor
conditions,which appearto result
from personalchoice and lifestyle. They include bupropion (zyban)
and nicotine
replacementtherapy, which are usedto support peoplewho are giving up smoking;
(xenical),
is
orlistat
which usedto treat obesity;and sildenafil(better known asviagra),
is
which used to treat erectile dysfunction. It is possibleto treat theseconditions
drug
in
therapy
without
somecases,by encouragingpeopleto changetheir lifestyle
behaviour.
I wish to examinewhether lifestyle drugs shouldbe prescribedon the
and
NHS.
Gilbert, Walley and New (2000: 134 1) suggestthat lifestyle drugsmay be definedas
those,which are used for 'non-health' problems,or for problemsthat lie at the margins
health
be
However,
of
well-being.
and
we should cautiousabout simplifyingthe
drugs
be
have
for
different
these
they
can used
classificationof
since
conditions,and
a
be
numberof properties, someof which can classedas 'therapeutic' while othersare
hormone
(2001)
Ballard
be
'lifestyle'.
the
to
to
cites
exampleof
related
considered
for
drug
is
the
HRT,
therapeutic
therapy,
relief of
used
when
which
replacement
is
if
it
lifestyle
benefits
for
to
be
taken
maintainyouth
potential
symptoms,yet can used
from
is
diabetic
for
be
libido.
Viagra
the
manwho suffering
or enhance
can prescribed
be
dysfunction,
and canalso
the associatedcomplicationsof neuropathyand erectile
Our
his
is
healthy
for
sexualperformance.
the
man who unhappywith
prescribed
depend
NHS
be
the
drugs
upon
may
these
on
prescribed
to
should
attitudes whether
"
lifestyle
for
being
wish.
drug
is
a
or
need
medical
the
a
used
whether we consider
lead
in
turn
can
13Of course, the thwarted lifestyle wish may become a psychological problem which
to mental illness and the need for medical treatment.
207
There are a number of arguments,which
suggestthat lifestyle drugs shouldnot be
prescribedon the NHS. Firstly, the NHS cannotfund unlimited health
careandif
lifestyle drugs are funded then it is inevitablethat
other treatmentswill be limited.14
Even if predicted costs of lifestyle drugs are
exaggerated,the costswill be enormous.
Secondly,it might be proposedthat people shouldbe
ableto changetheir lifestyleand
with education,persuasionand support,they shouldbe ableto control their behaviour.
There should not be a needto resort to drug therapies,when
in
changes lifestyle can
improve the condition. Indeed, conditions suchas obesity,smoking
andhigh
be
better
treated by a changein lifestyle so that the underlying
might
cholesterol
be
problem can addressed.If people are treatedwith drugsthen they maybecome
dependentupon the drugs and the underlying problem will not improve. People may
former
behaviour
drugs
to
the
relapse
when
are discontinued.
Thirdly, it might be proposedthat the NHS shouldtreat medicalneedsonly. People
fund
lifestyle
drugs
for
if
to
themselves,
could choose
and when they chose. Other
lifestyle
be
into
drugs
funding
NHS.
therefore
the
peoplewould not
coerced
on
However, I proposethat the NHS shouldfund somelifestyle drugs,evenif the costs
be
help
failing
than
Firstly,
takers
to
the
greater
may
even
risk
are significant,
costs of
NHS
the
drugs.
For
to
lifestyle
the
are
the costs of
costs of obesity
example,
Office
Audit
that
form
National
In
2001,
February
the
estimated
a report
enormous.
is
Of
this
(Moore
2001).
L485
over
NHS
course,
the
a
year
million
obesity cost
alone,
due
days
lost
to
the
associated
the
to
working
of
community
and above any costs
those
back
of
problems
pain, and the physical and psychological
complications, such as
heart
both
in
factor
key
is
coronary
risk
people who are obese. Further,, obesity a
14Wlitfield (1999: 14) suggeststhat there are 1.8 million men who suffer complete erectile
NHS
the
The
to
could
dysftmction.
costs
dysfunction, and a further 8 million who suffer partial
for
therefore be tens of millions of pounds a year unless some restrictions are placed on prescriptions
Viagra.
208
diseaseand type-2 diabetes." If
obesity is prevented,or treated,then future health
care costs will be reduced. The financial costs of lifestyle drugs
shouldthereforebe
balancedagainstthe savingsthat canbe
madeby preventingfuture chronicillness.
Secondly,it is likely that many people
are not ableto changetheir liflestyle,andwill
find it difficult to maintain any change. More
peoplewill successfullychangetheir
behaviourwith the support of lifestyle drugs. For
example,there is convincing
evidencethat a higher proportion of peoplewill be ableto stop smokingwith the
support of nicotine replacementtherapy (Royal Collegeof Physicians2000: 143). It is
probablethat somepeoplewill be ableto lose weight more successfullywhile using
drugs,which reduce fat absorption,suchas Xenical.
Thirdly, the NHS alreadyfunds drugs, which are neitherlifesaving,nor a treatmentfor
illnessor injury. For example,oral contraceptivesare widely prescribedto healthy
women allowing them to plan pregnanciesat their convenience.It is not consistentto
denylifestyle drugs on the basisthat the NHS shouldonly fund drugsfor medical
needs. Whether the NHS shouldfund contraceptivesand abortionsis of coursea
relevantquestion. I suggest,though, that the NHS is justified in funding these
treatments. Firstly, the costs of supportingunwantedpregnanciesand obstetriccare
be
may more expensivethan the provision of contraceptivesandgynaccological
it
Secondly,
financial
both
in
terms
appearsthat
services,
costs and personalcosts.
of
the public supports 'family planning' on the NHS, evenif it is not meetinga medical
needas such.
" The National Service Framework for Coronary Heart Disease(Department of Health 2000: 17)
NHS
should
agencies
the
that
importance
partner
and
the
states
and
stresses
of smoking cessation
Later
the
this
local
in
year,
in
the
population.
contribute to a reduction the prevalence of smoking
National Service Framework for Diabetes will be published and it seemsprobable that one of
in
the
to
reduction of obesity the population.
standards will relate
209
The ongoing developmentof lifestyle drugs
will ensurethat the rationing debate
continues. There will be a needto make decisionsabout which patients
be
should
treated, and which conditions shouldbe treated on the NHS. I
proposethat policy
makersand advisory bodies suchas NICE shouldestablishexplicit guidelinesand
judgements
individual
that
lifestyle and desertshouldnot be used
emphasize
about
in
the selectionof who is allocatedthesedrugs. This approachis justified because the
of
difficulties
practical
of assessingwhether a persondeservestreatment)andthe
consequencesof placing doctors in the position ofjudge and policy enforcer,as
discussedin chapter six.
However, decisionsabout who shouldbe allocatedlifestyle drugswill haveto be
I
made. proposethat guidelinesabout which conditionsshouldbe treatedwould be
justified. For example,severeasthmaticsmight be prescribedanti smokingdrugs;
diabeticsmight be prescribeddrugs suchas xenical for obesity;andthe elderlymight
be prescribedthe anti flu drug, relenza. Thosepeoplewith life threateningconditions
be
drugs
in
healthy
lifestyle
in
them
that
should allocated
adoptinga
order to
will assist
prevent complications.
In conclusion,I believethat a range of treatmentsand lifestyle drugs shouldbe
harm
drug
lifestyle
ban
blanket
A
NHS.
to
may
supply a particular
availableon the
diabetic
defined
the
have
manwho
medicalneeds,suchas
specificpatientswho
clearly
haserectile dysfunction. I have proposedthat it is not fair to allocatelifestyle drugs
because
lifestyle,
healthy
have
have
to
not maintaineda
or
according whether patients
However,
decisions.
difficulties
rationing
since
the
such
making
of
of
practical
fair
it
is
drugs,
to select
decisionswill haveto be madeabout the allocation of these
be
priority.
as
a
treatment
allocated
should
certain clinical conditions where
210
ChapterEight
LIFESTYLE AND ACCESS TO HEALTH CARE
8.1
Conclusions
211
8.1
Conclusions
I have chosento examineindividual responsibility,justice
and accessto healthcarefor
a number of reasons. Firstly, rationing in health careis inevitable' and is widely
be
to
acknowledged
a global issue(Coulter and Ham 2000). As new medical
treatmentsand lifestyle drugs are developed,and geneticscreeningand enhancement
becomea reality, the demandson health carewill increase. Giventhat
resourcesare
limited, decisionswill haveto be madeabout who shouldbe treated,,becauseit
will not
be possibleto treat everyonewith the treatmentof first choice. In this thesis,I have
how
to ration fairly.
explored certain aspectsof
Secondly,lifestyle is one of the criteria that could be usedto ration healthcare. For
denied
immediate
be
low
they
smokers
are
sometimes
surgery
and
may
given
example,
decisions
list.
have
Chapter
Two,
I
In
that
the
aboutthe
argued
priority on
waiting
be
based
on a numberof criteria
allocation of scarcemedicalresourcesshould
including medicalneed,patient desire,and clinical and cost effectiveness.Where
factors such as age and lifestyle affect clinical effectivenessthey are alsoindirectly
be
the
to
have
I
this
that
situationwhere
contrasted
should
suggested
relevant.
lifestyle
former
basis
individuals
their
be
the
to
of
on
might
allocated
medicalresources
decisions
directly
is
lif6style
to
have
I
relevant
In
this
thesis,
exploredwhether
per se.
in
patients
be
all
not
the
when
treated
scenano,
unfortunate
aboutwhich patient should
be
can treated.
Nation'
Healthier
Our
Lives:
'Saving
Thirdly, governmentpolicy documentsincluding
'
Dependable.
Modern.
NHS
(Departmentof Health 1999) and The New
individual
to
included
reference
(Departmentof Health 1997) haveincreasingly
forfeit
that
should
is
people
Currently
health.
for
there
no suggestion
responsibility
The inevitability of rationing is discussedin Chapter 1.
212
health care if they behaveirresponsibly
and continueto take known risks with their
health. But what should happenif people
chooseto ignore governmenthealth
do
warnings and not adopt a healthylifestyle? Is it justifiable to
withdraw or delay
health
related
care and give priority to those individualswho havemaintaineda healthy
lifestyle?
Doctors and nursesoccasionallyblamepatientsfor their behaviourandthey may scold
and reprimand patients accordingly. By doing so, it appearsthat healthcare
holding
professionalsare
peopleresponsiblefor their lifestyle andblarning(even
it.
Advertisements
from the British Heart Foundation
them
punishing)
on account of
(2001) show smoking, diet and a sedentarylifestyle asthe causesof heart diseaseand
death.The messageappearsto be that individualsshouldchangetheir behaviourin
is
lifestyle
influence
ill
health.
However,
the
to
of
sometimesexaggerated
order prevent
health.
have
ill
I
is
factors
it
to
that
only one of many
examined
contribute
and
ignoring
individuals,
lifestyle
focus
it
is
fair
the
to
other
of
while
on
whether
factors.
predisposing
depth,
in
has
been
justice
distributive
not so much
Finally, while the notion of
explored
health
in
issues
for
implications
as
been
such
has
policy
care
to
the
given
attention
hard
(1996,198)
about
remain
Daniels
still
As
Norman
questions
states
rationing.
incur
'voluntarily'
extra risk and
'how to distribute the burdensthat result when people
the
discussed
have
'
doing
I
contemporary
by
of
some
health
so.
care
swell the costs of
for
implications
the
of
allocation
justice
their
distributive
theoriesof
and explored
healthcare resourcesbetweenindividuals.
justice
distributive
theories
of
have
I
(Chapter
Three),
various
In this thesis,
reviewed
these
that
precludeusing
of
none
and argued
decisions
in
lifestyle as one of the criteria
Liberalswill
individuals.
between
about the allocation of scarcemedicalresources
213
emphasizethat people shouldbe allowed to maketheir own
choicesabout lifestyle,
including the choice to indulge in
unhealthyand risky activities. However, liberalswin
also argue that there is no obligation for othersto provide health
careif peoplebecome
ill or injured. If people havevoluntarily contributed
to their needfor healthcare,why
shouldanyoneelsehave to help them?
The communitarianmay acceptmore coercivemeasures
and enforcementof legislation
in order to promote the health and welfare of the community. Thereis
no suggestion
that it would be unfair to give priority to those membersof the communitywho have
adopteda healthy lifestyle, if choiceshaveto be madebetweenpatients. Indeed,it
be
might suggestedthat sucha policy would encouragepeopleto avoid known risks
and take active steps to maintain a healthy lifestyle, so promoting the welfare of the
community generally.
The theories of distributive justice, which were includedin the review, do not suggest
that it would be unfair in principle to use lifestyleper se as one of the criteria in
decisionsabout the allocation of health care resources.Nevertheless,evenif
inclusion
have
lifestyle
I
that
the
theoretically
of
considerationsof
relevant,
argued
are
this criterion in these decisionswould be unfair in practice, exceptin caseswhere
lifestyle adverselyaffects clinical outcomes. Doctors and other healthcare
behaviour
former
lifestyle
judgements
the
of
and
about
professionalsshould not make
their patientsfor a number of reasons.
If
Four.
Chapter
in
discussed
involuntary,
Firstly, risk taking is either voluntary or
as
is
denial
by
treatment
not
lifestyle choicesare involuntary, blame or punishment
of
health
indeed
doctors,
care
defensible. However, I have suggestedthat
any other
or
involuntary
is
and
behaviour
judge
or
voluntary
whether
professionals,are not ableto
that it would therefore be unfair to use this criterion.
214
It is difficult for doctors to judge whether behaviouris
voluntary
or involuntary
becauseit is not a medical assessment,
but rather a characterassessment
for which they
haveno specialtraining. In addition, in order to
make suchjudgementsdoctorswould
haveto make intrusive inquires which might violate the
privacy of their patients.
Further, the extent to which lifestyle is a contributory causeto disease in'
and jury
is
It
obvious that a variety of factors will contributeto the needfor healthcare
varies.
it
follows
judgements
that
and
apportioningblameare likely to be unreliable. If health
focus
careprofessionals
exclusivelyupon individualsandtheir lifestyle,thereis a risk
blarning.
is
This
because
victim
of
unfair
other peoplemay havecontributedto the
for
health
Such
need
care.
an approachmay also detract attentionfrom the wider
factors
environmental
which contribute to ill health.
Supposethe lifestyle choices and risk taking are voluntary. Even so, I maintain that
the delay or denial of medical treatment is inappropriate. In certain cases,the risk
taking may be excused or justified. People may offer excusesto explain and defend
their unhealthy behaviour, claiming that they have been unduly influenced by others, or
that there are extenuating circumstances to explain their behaviour. Alternatively,
do
in
been
has
behaviour
the
thing
to
the
that
their
right
peoplemay suggest
justified.
For
been
has
the
mother
young
the
example:
that
risk
circumstancesand
keep
her
to
that
calm
it
because
is
the
enables
and
relaxations
pleasures
one of
smokes
be
flat.
We
in
cautious
her
should
look
the
small
a
of
three
confines
children
and
after
individual
by
justified
be
the
It
behaviour.
for
her
blaming
this
might
about
between
distinguish
and
excuses
to
is
It
the
easy
not always
case.
circumstancesof
justification and doctors are not well placedto judge.
delayed
withdrawn
or
blameworthy,
the
of
if
lifestyle
Even
punishment
choicesare
be
to
'punishment7
This
seems
taking.
disproportionate
is
to
risk
medicaltreatment
doctor
primary
the
whose
of
role
incompatible
traditional
the
caring
with
callous and
215
is
purpose to treat patients accordingto their needs. In addition,usingthis criterion
will underminethe trust which underlieseffective communicationbetweendoctors and
their patients, particularly if treatmentis delayedor withdrawn in order to save
for
resources other or potential patients. Finally, it shouldbe noted that there maybe
more effective ways to encouragepeopleto improve their lifestyleby educationand
forms
discussed
in ChapterFive.
of persuasion,as
some
The recent emphasison explicit rationing and on opentransparentdecisionmakingwill
discussion
be
health
to
about which criteria should used ration
allow greater public
for
doctors
be
It
to
andmanagers
possible establishcertainguidelines
care. will
include
the
I
these
that
to
the
should
guidelines
processof rationing. propose
relating
former
health
to
the
doctors
careresourcesaccording
will not allocate
statementthat
lifestyle of their patients, exceptjust in as far as it hasaffectedthe probableclinical
future
if
to
prescribed
outcomesof treatment. patientsare unwilling cooperatewith
the
to
is
justifiable
it
where
to
patients
other
then
allocateresources
treatment,
be
favourable,
effectively.
more
be
used
can
resources
scarce
and
more
outcomeswill
that
has
(NICE)
Excellence
Clinical
recommended
for
recently
The National Institute
be
those
to
who
drug)
patients
(an
prescribed
Xenical
only
should
anti-obesitY
2001).
(Derbyshire
diet
programme
exercise
and
maintaina calorie controlled
have
demonstrate
they
that
have
to
NICE
will
According to these
guidelines,patients
body
five
their
least
lose
of
cent
per
they
at
must
lost weight and met set targets:
be
drug
the
target
will
this
do
If
they
achieve
not
three
months.
weight within
the
dependent
patient
is
upon
drug
therefore
this
The
of
allocation
withdrawn.
the
to
complete
demonstrating
commitment
a
behaviour
and
maintainingcertain
medicaltreatment.
216
This assessmentof current behaviouris different from judgements
about former
lifestyle. Firstly, treatment is being provided, but
be
discontinuedif it is not
will
clinically effective for whatever reason,including non-compliance.Secondly,the
be
informed
patient can
of the proposedconditions
and requirementsfor ongoing
treatment: a contract could be negotiatedand agreedbetweenpatient and doctor.
Sinceresourcesare limited in health care,it is justifiable to
allocatethem to cases
is
the
patient able and willing to cooperateand the outcomesare beneficial.
where
This is not a decisionbasedupon desertand former behaviour.
The NHS hasboth a legal and a moral duty to provide reasonablehealthcarefor
from
finances,
everyone
which are raisedby compulsorytaxation. If risk takers,as a
group, use more than their fair shareof the resources,it follows that they may harm
those people who have maintaineda healthylifestyle, who may be deniedthe resources
that they need. Individuals do have a correspondingresponsibilityto attemptto stay
healthy so as not to unnecessarily burden their fellow taxpayers. People should be
lifestyle
health
by
lifestyle
healthy
education, support, and
encouraged to maintain a
drugs on the NHS, if appropriate. Indeed, it is reasonableto do more than provide
information, where people may have difficulty acting on their own wishes in the future.
for
justifiable,
the young and
Persuasion and warnings are therefore
particularly
has
information
be
the
is
known
immature.,and where behaviour
to
addictive, or where
to compete with advertising or accepted cultural norms.
by
taxes
for
NHS
on products
the
placing
is
It also reasonableto raise extra money
in
happens
taxation
the
on
This
health
known
already
risks.
associatedwith certain
dangerous
items
to
be
related
it
to
some
cover
tobacco and alcohol and could extended
in,
watch
or
partake
In
who
this
people
way,
events.
or
permits
sports: equipment,
the
NHS,
to
potential
for
funds
cover
the
dangerousactivities will contribute extra
behaviour.
their
costs of
217
If individuals have not maintaineda healthylifestyle (for whateverreason)it is
not
justifiable to withdraw or delayhealth care as a 'punishment'. I have
it
that
argued
will
be difficult to determinewho hasmadean effort to avoid risksl andfailed becauseof
beyond
their control, and thosewho havemademinimalor no effort to
circumstances
Unless
is
there
avoid risks.
convincingnew evidenceto demonstratethat health
behaviour
is
it
is
related
voluntary,
not justifiable to penalizepotentialpatients,who
havetaken risks. Thesepeople shouldbe treated on the NHS, regardlessof their
former lifestyle, except in those individual caseswhere lifestyle hasadverselyaffected
the probable clinical effectivenessof treatment.
218
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