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Oxford Debates Cont’d – Opposer’s Opening Statement

Part of the debate "The NHS should not treat self-inflicted illness"

Opposer: Charles Foster (Barrister & teacher of medical law and ethics at
Oxford. He is attached to the Ethox Centre and is an Associate Fellow
of Green Templeton College)
Opening Statement

'The NHS has shown the world the way to healthcare, not as a privilege to be paid for, but as a fundamental human right', proclaimed the Department of Health in 2008. 'The values of the NHS – universal, tax-funded and free at the point of need – remain as fundamental today to the NHS as they were when it was launched in 1948.'

These values are important. We abandon or dilute them at our peril.

Mark Sheehan suggests that we have to grow up: to shoulder responsibility for our own actions and omissions. Why, he asks, should society pick up the bill for my stupidity?

There are many answers. Some of them will be ventilated over the next few weeks. But here are a few:

   1. Society should pay because, unless it does, the whole notion of society evaporates or becomes malignant. Society isn't a club for perfected saints. Decent societies acknowledge that people make mistakes, and don't withdraw the privilege of membership from people who take up smoking, or fail to give up drinking. There was a chilling and revealing phrase in Mark Sheehan's opening statement. Speaking about people who smoke and drink too much and exercise too little, he said that 'there is, really, no good reason why people lead their lives in this way.' And because there is no good reason, he went on, society should refuse to underwrite the financial consequences of the rakes' bad decision-making.  This sort of argument should raise all sorts of hackles. A good reason according to whom? Who is Mark Sheehan, or 'society'  to say what amounts to a good reason? Where are these vocal but notoriously elusive 'right-thinking people', so often appealed to by lawyers? And what is the source of their wisdom?  Perhaps smoking and drinking are the highest human callings. I personally doubt it, but I'm not prepared to kill someone who thinks so – which is what withholding medical treatment from them might amount to. If you're prepared as a society to say of any human choice short of obvious crime: 'That's beyond the pale', where do you stop? Do you withhold society's favours from someone who holds a particular religious belief? Or whose skin is a particular colour?

   2. It will often be impossible to say, as a matter of medical fact, whether a particular illness is self-inflicted. Smoking certainly causes some lung cancers, but X's lung cancer might be wholly unrelated to his smoking. Why should X be condemned to death by a scientific paper describing a correlation which is irrelevant to his circumstances?

   3. Even where the connection between a disease and a particular voluntary course of conduct is clear, that 'culpable' course of conduct will often itself have been prompted by other factors over which the person had no control. A smoker might have been propelled into smoking by depression; sexual abuse might have turned a teetotaller into an alcoholic; a genetic tendency to addiction might have overwhelmed the best of intentions.  Few of us are as free as the grand, cold theories of absolute individual responsibility presume.

   4. The idea is unworkable in practice. If one decides to adopt an exclusion criterion such as 'smoker', one has insuperable difficulties of definition and evidence. How many cigarettes does one have to smoke to qualify? Over what time period? Of what tar content? Pipes? Cigars? Barbeques? What if they don't inhale? And how do you prove any of this stuff? What if, as well as being a qualified smoker, they also run a marathon a day? Should no credit be given for that? And so on. 

Of course resources are important. We live in a world of infinite human suffering but finite financial resources. Yes, to treat one patient is necessarily to deny treatment to another. Yes, hard decisions about resource allocation have to be made, and have to be made using clear and consistently applied criteria. But the criterion of 'self-inflicted' is not clear. Even if it were, to apply it consistently would be to infect the NHS with some nasty and widely repercussive presumptions about the relationship between the broken individual and the society that once thought it was obliged to bind him up. 

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