Oxford Debates Cont’d – Proposer’s update 1

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

Proposer: Dr Mark Sheehan
Update 1

There is a robust system in place in the NHS that grapples with questions like ours regularly. Far from these being my decisions, or the decisions of 'right-minded people', this system is open, publicly accessible, and accountable. Indeed, given the constraints, it is one of the fairest ways of making the kinds of allocation decisions that must be made.

The questions that confront NHS commissioners involve precisely the sorts of issues that concern us. They are not about whether to kill a particular individual but about how to prioritise services and allocate resources. In Foster's terms these are not decisions about whether to kill or let an individual die but decisions about which individuals to choose between. The situation is more akin to a transplantation decision where there is one liver and two potential recipients. Who should receive the liver, the child or the alcoholic? Alternatively — should the intensive care unit admit a car accident victim or a person who has just narrowly failed in their third attempt at suicide?

At the more general policy level there are difficult questions that need to be addressed about the kinds of services that the NHS should provide. When we consider the range of services that could be funded, rather than those related to lifestyle-related illness, we see a choice between different kinds of suffering. Palliative care provision is notoriously underfunded; we want the best and latest drugs for cancer sufferers, we think infertile couples should be given a fair go at IVF and we think that primary care should be available around the clock. Each of these competes for resources with the treatment of self-inflicted illness.

As Foster agrees, smoking does indeed cause some lung cancers, heavy drinking causes some cirrhosis, and persistently eating badly without exercise causes some morbid obesity. Understanding causation here is not hard and is not about the difference between pipes and cigarettes or between three glasses of wine and four. The cases in question are not, as Foster would have us believe, marginal or borderline. In the cases in question the evidence is clear — the liver was damaged by alcohol, the suicide attempt caused the trauma that requires the intensive care bed, and the behavioural and psychological therapy that was provided was ignored or dismissed.

Clearly there will be exceptional cases, like Foster's abused teetotaller, but the system is sophisticated and already handles exceptional cases where particular mitigating circumstances are decided upon.

We must pay more than vague lip-service to the making of "… hard decisions about resource allocation". Life-sustaining treatment is currently being denied to sick individuals just because those who have lung cancer from smoking excessively when they could have chosen not to, are treated. This appears unjust.

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