Part of the debate "The NHS should not treat self-inflicted illness"
Proposer: Dr Mark Sheehan (Oxford BRC Ethics Fellow at the Ethox Centre and
James Martin Research Fellow in the Program on the Ethics of the New
Biosciences)
Opening Statement
We generally think that people are entitled to live their lives in the way that they see fit, in a way that best coheres with what they take to be meaningful and valuable. This is perhaps the central tenet of western liberal society. Liberal society is centred on permitting and perhaps even encouraging, different conceptions of 'the good' and experiments in living. Alongside this freedom, however, comes a responsibility for the decisions that one makes. Because society remains a collective effort the freedom to choose to live in a certain way brings with it responsibilities — here, responsibilities for the consequences of our choices.
Justice on this model requires that the government should provide for those who are disadvantaged by their situation and are unable to live as they would because of circumstance — those who, through no fault of their own, are poor or sick or without the necessities of life. In the normal course of events people get sick and, in the UK, it is the business of government to provide for these people. This provision, however, does not necessarily extend to those who are sick through their own fault or through the particular lifestyle choices that they have made. The state should protect people from the 'ravages' of circumstance not from the consequences of their own choice. When someone freely chooses to live life in a particular way, he, not society must, at some point, shoulder the responsibility for those choices.
It is not as though the relationship between the choices and the illnesses is uncertain. We know that smoking is bad for people and we know that smokers are more likely to die early and unpleasantly. Similarly, we know that heavy drinkers would be better off if they did not drink heavily and that people who eat badly and get too little exercise would be better off if they adjusted their lifestyle. Given this there is, really, no good reason why people lead their lives in this way. When we speak generally about the value of letting people live their lives as they see fit and according to their own view of what constitutes the good life, this does not imply that they can do and value just anything. 'Experiments in living' are designed to teach us something — there is no point reinventing the wheel for every generation.
Given that resources are scarce and that we don't have enough to go around, we need some way of fairly distributing the resources that we do have. Difficult decisions are already being made in the NHS but it is clearly not enough. In some cases treatments are not funded because they cost too much or because they only might work. Holding individuals accountable for their choices is one criterion that is fair and consistent with the basic tenets of our society. When used alongside other criteria, it can help to make sure that the resources that we do have are distributed justly.
Clearly there will be some difficult cases in determining which kinds of conditions and the degree of excess that will count as enough to warrant the various forms of exclusion, but this does not prevent there from being some cases that are clear: a pack-a-day smoking habit looks to be one. This is not the beginning of a slippery slope. There is a clear evidential basis for this and the 'restrictions' could be applied on strictly defined criteria.
Of course there are various steps that society might take to prevent people engaging in these clearly dangerous activities alongside restricted or deprioritised access. Education, perhaps aggressive and targeted, would be a key component, as might heavy taxation. But perhaps a very effective driver of change would be to combine education with treatment. Mandatory attendance at smoking cessation classes, personal targets and progress assessments might all be used to change the way in which those who continue to choose the unhealthy option have access to health care. This does not represent a strong form of restriction of access but it does represent a strong condemnation of these practices translated into action steps.