Oxford Debates Cont’d – Opposer’s update 1

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

Opposer: Charles Foster
Update 1

It simply won't do to underplay the practical difficulties posed by this motion. The motion is not 'The NHS should not treat those illnesses which can be shown beyond any doubt to have been self-inflicted', but 'The NHS should not treat self-inflicted illness'.  The world of medical causation is simply not as straightforward as Mark Sheehan suggests. To reiterate: to prove a link in the general population between smoking and lung cancer is a very different thing from proving it in an individual patient.

There are no 'robust' or indeed any systems in the NHS for dealing with this sort of issue. Nor can there be. Questions of individual causation are argued expensively before the courts in clinical negligence cases. They are notoriously nightmarish. The same job can't be done by committees, however enlightened or well meaning.

Even the cases of obviously self-inflicted injury aren't simple. Does a decent society say to the suicide victim either: 'You autonomously slashed your wrists. We respect that decision. Bleed on'; or 'Bad decision. Clearly self-inflicted.  Our criteria say that you mustn't take up a hospital bed that could be used by someone who is suffering from something that we can't (yet) demonstrate is self-inflicted'? The answer, hopefully, is no on both counts. There is every reason to suspect that depression has truncated the patient's autonomy, and every reason to view the depression as society's problem, not merely the patient's.

And now we're getting to the ethical nub. Whether you're dealing with a cancer caused by bad diet, bad air, smoking, genes and TV addiction, or an overdose of paracetamol caused by childhood trauma, unemployment, a smashed relationship or the death of a parent, you can quite easily say that as a matter of causation it is not entirely the patient's fault. It is at least in part the fault of the nexus of which that patient is a part – the nexus that we call society. And it is society that pays the NHS bills.

But society's obligation to that patient shouldn't depend on saying that everything is society's fault. Society should pay because, regardless of fault, society exists for its members, and members who are ill are still members. In fact in any properly oriented society they should be particularly valued members.   

Back to practicalities. The systems that Sheehan romantically describes as 'robust', 'open', 'publicly accessible and accountable' are fine for adjudicating on the questions they are set up to judge. They make unenviable but inevitable decisions about NHS funding. They may conclude, for instance, that heavy smokers shouldn't be given coronary bypasses. But that's because continued smoking is likely to cause the bypass to fail. That's common sense, not callousness. And that type of decision doesn't help Sheehan at all.

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