Every day medics are faced with crucial patient treatment choices. Maria McCann argues that there are no simple answers when it comes to deciding who will live and who may die
We know that for the National Health Service, it is not possible to provide every type of treatment to everyone. In the midst of competing demands on resources, some sort of selection and prioritisation must take place. When choosing who should get treatments and therapies, or scarce healthcare resources such as organs, is there good reason for preferring to help some patients over others? The case of Northern Ireland teenager, Gareth Anderson, has divided public opinion. A binge drinker, he has been told he needs a new liver — or may have just weeks to live. NHS guidelines say he must first steer clear of alcohol for six months, but given his plight, should he jump the queue?
Perhaps we intuitively would treat a younger person before an older one; especially if we felt the older person had had a ‘fair innings’, however the argument may swing back towards the older person particularly if she is a mother with dependent children.
These intuitive arguments, favouring some people more than others, identify areas of discrimination which actually say we value some people more than others when it comes to allocation of health care resources and nowhere is this more contentiously debated than in the area of self- inflicted ill health.
While I believe that we hold personal responsibility central to our morality, perhaps it is not so convincingly applied when it comes to evaluating ill health and, most particularly, when we look at the debate happening with regard to the allocation of scarce health care resources such as organs to those who are seen as having self-inflicted poor health. It might seem fair and sensible to penalise those who risk their health and who are potentially harming others by consuming limited health care resources.
Perhaps doing so would even discourage people from pursuing choices that risk damaging their health: their eating habits, whether or not they smoke, their consumption of alcohol, their use of ‘leisure’ drugs, the dangerous sports they take part in, the dangers of not taking part in sport and becoming unfit and obese, their responsible or irresponsible sexual behaviour, set the context for claims to prioritise or deprioritise in the allocation of healthcare resources.
If the distribution of health resources is a public responsibility, do those who bring about their own ill health weaken that public responsibility to them? This seems to me a dangerous route to go down.We also know that ill health is broadly related to socioeconomic status — with the most disadvantaged tending to have less control over their working and living environments, and that this sense of lack of control leads to stress responses, which predictably cause conditions such as atherosclerosis and obesity. So it follows that in many cases people are not entirely personally responsible for behaviours which bring about ill health.
There are further limits on how much the personal responsibility can apply when it comes to ill health: there is the issue of the environment and the upbringing of children within health compromising situations where diet and role model behaviours leave a legacy of ill health and a lifestyle that leads to self-inflicted ill health. Are ‘the sins of the father’ to be laid upon the children? Moreover, are the interests of children or dependents who may suffer if a parent is not treated because of self inflicted illness, to be disregarded?
Health care should be provided irrespective of the extent to which a person may have contributed to their own illness, even though this fact adversely affects others to some extent. While this may not always seem fair, fairness should not be the most important reason for supporting the individual responsibility argument.
We have a moral imperative to relieve suffering and to strive towards enabling each person to be reinstated or placed in a position where they can flourish, thrive and assume responsibly at some later stage in their lives.
We all have a duty to encourage and promote morality, but to do so by choosing between candidates for treatment on moral grounds is not simply the promotion of morality but the punishment of immorality. To choose to let one person rather than another die on the grounds of some moral defect in their behaviours or character is to take upon ourselves the right not simply to punish, but capitally to punish, offenders against morality.
The patients whose behaviour cause greatest criticism, and elicits least public support for equal access to health care are smokers. A report in The Observer noted that, according to four out of 10 doctors, smokers and drinkers should not get heart by-passes and liver transplants on the NHS.
I see little merit in the argument often advanced that depriving smokers of healthcare would act as an effective deterrent. When it comes to smokers claims on health resources, there is compelling evidence the costs incurred by the smoking population are 7% and 11% lower for male and females respectively.
In addition if all smokers stopped smoking, costs would initially drop (by up to 25%) but with time this benefit reverses to become a cost. The reason being that smoking related mortality declines and the population starts to age; growing numbers of people in the older age groups mean higher costs for health care. Smokers save the state money by dying early.
While resource allocations ought to be based on medical indicators not lifestyle, it is accepted that the outcomes of some treatments are less successful in those who are either obese or smoke than in those who are neither, and therefore on the basis of the cost effectiveness of treating the healthier group there is justification in prioritising them by denying treatment to the others.
These questions over access to health care resources for those with self-inflicted illness should not come down to weighing up the moral worth of an individual where doctors would be expected to judge the behaviour of a patient. But where will these judgments lead? The skin cancer victim who has used a sun bed, the person injured in a crash because they were not wearing a seat belt. It is difficult to decide, if indeed it is at all appropriate to consider.
The question arises as to whether patients with alcohol-related illness should be excluded from waiting lists for liver transplants or should be given lower priority ratings.
The case of George Best divided public opinion: while his fans and many of the public supported him receiving the transplant , there were many critics who felt there were more deserving cases for NHS surgery. The arguments against George Best receiving the transplant cited: the cost of the operations at £60,000; the deserving case of the 150 patients on the transplant waiting list; Best’s age, and, most significantly, his lifestyle of alcohol abuse. George's clinician Professor Roger Williams placed conditions for suitability for transplant which required one year of abstinence from alcohol. This condition was met by George. Unfortunately for the organ donor registry campaign; the organ was, perceived by some as wastage since George Best resumed his drinking and later died.
This view presumes he died due to his drinking and does not take account of other factors such as complications with antirejection medication or other factors.
In George Best’s case I would argue that the liver he received was not “wasted”: he lived for three years and three months following the liver transplant and no doubt his loving family and friends valued this precious time.
Maria McCann is a public relations consultant specialising in health care communications