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Oxford Debates Cont’d – Proposer’s Closing Statement

Part of the debate "The NHS should not treat self-inflicted illness"
Proposer: Dr Mark Sheehan

Closing Statement

What is most difficult about topics such as this one is that there are clear intuitions on both sides. These intuitions pull against each other and tempt us to focus on extremes at either end. The solution lies in the middle, where we can respect the desire to care for all those who are suffering as well as taking seriously the network of rights and responsibilities on which society is based.

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Oxford Debates Cont’d – Opposer’s update 2

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

Opposer: Charles Foster
Update 2

Dr. Sheehan has fairly and inevitably surrendered. The motion as it stands is wholly unarguable.

But he contends that there are still important matters to discuss. I agree. Let's look at the 'subset of extreme examples' he relies on, where it is blindingly obvious that injury has been self-inflicted. The three clearest examples are perhaps attempted suicides, injuries resulting from dangerous sports, and some road traffic accidents.

We need to start by chasing away one red herring: insurance.  Of course bungee jumpers and parachutists should be insured. Insurance is mandatory for drivers. I have no difficulty with the proposition that the NHS should recoup the cost of care from the bungee jumper's insurer. But let's suppose that the insurance company won't pay. There could be many reasons. The jumper's wife might have failed to post a letter; the tour operator, unbeknown to the jumper, might not have been on the insurer's approved list; the insurer might litigate long and hard to avoid liability on a technicality.

Read More »Oxford Debates Cont’d – Opposer’s update 2

Oxford Debates Cont’d – Proposer’s update 2

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

Proposer: Dr Mark Sheehan
Update 2

As Foster suggests we must be clear about the motion. So what might it mean to 'not treat self-inflicted illness'? If it means not treating an illness or condition that was in some way the result of choices of the patient, not only would the motion require that the NHS not treat the flu — if only people had no contact with each other — but it would be a complete waste of time to discuss.

The motion does raise an important issue, and a live issue, and so it should be given a sensible interpretation. Precisely because of this 'self-inflicted' must mean something like 'those illnesses that can be shown to be self-inflicted.' The background to all of this of course is the body of evidence surrounding particular kinds of life-style decisions. So when we refer to self-inflicted illness we do not mean all cases, but the subset of extreme examples where particular choices have been made and the knowledge that is clearly available in society has been ignored.

We also need to be clear about the ways in which the NHS might 'not treat.' First, 'not treating' can involve blocking access to particular care or procedures. Foster concedes that the processes in the NHS for making decisions about funding may conclude (apparently with some justification) that heavy smokers should not be given coronary bypasses — because they smoke. Clearly here, the choice to smoke by the patient means that they are denied treatment. The smoking causes the conditions that the make the coronary bypass likely to fail.

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How bad are heatwaves and flu epidemics?

The UK health media is currently focused on two natural threats to public health: one from swine flu, and the other from the heatwave currently affecting the country. Both flu epidemics and heatwaves frequently cause many deaths. For example, the August 2003 heatwave had a death toll in Europe of around 30,000, and a typical seasonal flu epidemic causes hundreds and thousands of deaths. Yet my impression is that, in the majority of the population, flu epidemics and heatwaves are not regarded as particularly great evils (flu pandemics, such as the current one, may be a different story).There's an obvious explanation for why they are regarded as less bad than killers such as road traffic accidents, wars and terrorism: these involve human action – and often human wrongdoing – in a way that flu epidemics and heatwaves do not. But flu epidemics and heatwaves also elicit a weaker reaction than many other natural events that typically kill far fewer people: for example, floods and earthquakes.

Read More »How bad are heatwaves and flu epidemics?

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.

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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?

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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:

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Oxford Debates Cont’d – Proposer’s Opening Statement

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.

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Oxford Debates – The NHS should not treat self-inflicted illness (Moderator’s Introduction)

Moderator: Dr Paula Boddington

Should the NHS treat self-inflicted illness? This question raises a plethora of different issues, about science, society, social policy, as well as philosophical questions about human nature and individual freedom.

The best use of health care resources will always be debated. How much money should be spent on health? How efficiently can it be spent? How should it be divided within the healthcare system? These can never simply be questions of economics but also raise vitally important questions about values. This debate about what treatments the NHS should offer is taking place in an economic climate where there is a call to curtail public spending. Would refusing to treat self-inflicted illnesses be a fair place to start to save money?

But money is only one aspect of this debate.

Read More »Oxford Debates – The NHS should not treat self-inflicted illness (Moderator’s Introduction)

More on drugs…

In a recent
entry on this weblog, Roger Crisp discusses the recent and controversial
“Release” advertising campaign on drugs (and its slogan “Nice People Take
Drugs”),
and rightly highlights the need for serious and widespread debate on drug
legislation. My home country, Switzerland, precisely had a debate on this issue
a few months ago, when we were called to vote on a popular initiative
purporting to decriminalize the use, purchase, consumption and possession of
cannabis (not of other drugs) – which would have meant placing the consumption
of this drug on a similar plane with that of tobacco or alcohol. This measure
was supposed to be accompanied by others, notably destined to protect young
people. On the 30th of November 2008, however, the Swiss people
rejected the initiative by quite a large majority.

Read More »More on drugs…