Monday, 30 April 2012

You get what you deserve

It appears doctors are increasingly of the view that certain treatments should be denied to the obese and to smokers. This was a relatively small, self-selecting survey, and certainly doesn't reflect the position of professional bodies, so it's wise to be cautious, but it does seem to indicate a trend towards the concept of the deserving and the undeserving sick.

It's easy to mock this on a number of pragmatic grounds. Obesity and smoking can both be symptoms of more profound disorders, rather than just self-indulgent lifestyles choices, while an obese employed 50 year old who has paid tax for 30 years arguably has a greater call on resources than a skinny teen who has never worked. There is also the issue of where you draw the line. Should skiers be denied treatment for broken bones on the grounds that they put themselves at risk?

The best answer is that health care in the UK is still (just) a public good and is made available as a universal right. To be deserving of health care requires simply that you be sick. This doesn't mean that treatments aren't rationed, or that clinical judgements aren't made on the basis of the individual patient, but it does mean that your non-medical circumstances and behaviour have no bearing on your access to health care.

Unfortunately, the concept of a right is one that has been under attack for some years, witness the regularity with which we are told that rights always entail responsibilities. A fundamental right is by definition unconditional. For example, human rights are so called because the only qualification is that you be human. That is why Abu Qatada has human rights. If Theresa May can prove that he is actually a fish, then she can pop him on a plane to Jordan tomorrow (she might have to ensure he had a clean tank of water for the journey, but that's about it rights-wise).

Philosophers distinguish between claim rights and liberty rights. In essence, the former entail responsibilities or duties while the latter don't. A worker has a claim right to be paid, so long as he has fulfilled his responsibility to work. A worker has a liberty right to withdraw her labour, unconditionally. Much of politics concerns attempts to recategorise between the two.

A more subtle interpretation of the survey is that GP commissioning, a centrepiece of the Lansley reforms, is beginning to worry doctors as it puts them in the firing line in respect of the inevitable decisions over rationing. Where once they could blame the local health trust, or even a specific hospital, they will shortly be the ones responsible for the postcode lottery. Shifting responsibility onto the patient is one way of avoiding that burden.

This requires patients to be increasingly assessed as worthy or unworthy, which harks back to the days before the NHS when doctors were often a powerful arbiter of social norms, and usually conservative to boot. The fat and smokers are easy targets, but how long will it be before other "undeserving" groups come into focus? How long before a religious doctor starts to cavil over birth control or abortion? If my assumption that drugs will sooner or later be reframed as a public health issue is sound, then we can expect some interesting debates about the worthiness of drug users when it comes to prioritising limited resources.

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