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Rationing/ Resource Allocation

Mind the Gap?

Much attention has been paid over the last week or so to An Anatomy of Economic Inequality in the UK, a government-sponsored study which has taken over ten years to produce: http://www.guardian.co.uk/society/2010/jan/27/unequal-britain-report

The study contains a huge amount of data, much of it on the gaps between richer and poorer groups. It turns out, for example, that the richest 10% own about one hundred times as the poorest 10%. Many appear to think that such inequality is obviously, in itself, a bad thing — something any government, especially one with its roots in socialism, ought to be doing something about. But in fact this is far from obvious. Imagine that each person in the poorest group were earning £100,000 p.a., and each in the richest group £10,000,000. Such a result would be described as an economic and political miracle. Or imagine that the government sought to deal with the real gaps between rich and poor merely by 'levelling down' the income of the rich to that of the poor. Given the absence of any trickling down, and the effects on incentives, the outcome of such a policy might well be to make everyone, both existing rich and existing poor, even poorer than they are now. The fact that the gap would have disappeared seems irrelevant in a situation when all have been made worse off.

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Obesity and Responsibility

There has been a good deal of discussion about obesity recently, since the Royal College of Surgeons criticized access to weight loss operations in the UK as a ‘postcode lottery’: http://www.guardian.co.uk/commentisfree/2010/jan/21/morbid-obesity-gastric-bands-nhs-costs

One common response – for example by Catherine Bennett in The Observer (  http://www.guardian.co.uk/commentisfree/2010/jan/24/homeopathy-obesity-gastric-bands ) has been that the question of unfairness shouldn’t be permitted to arise in the first place. Obesity, since it is self-inflicted, should not be treated by the NHS at all. Rather, the money should be spent on treatments for involuntary ailments, such as cataract operations or hip replacements.

Against this, it could be argued that interventions to cause weight loss, such as gastric bands, are in fact a highly effective use of NHS resources, since (a) they tend to work pretty well and (b) they save the costs of further treatment down the line for conditions which would otherwise have been caused by the obesity. This argument, however, fails to deal with the original deflection of responsibility for obesity onto the sufferers themselves. If they bring obesity on themselves, which then gives rise to further medical problems, then plausibly they have brought those problems on themselves as well. The NHS should refrain from treatment throughout.

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Are some ethicists really really ethical?

In this blog recently Simon Rippon discussed the empirical evidence collected by Eric Schwitzgebel that suggests that perhaps ethicists are no more ethical in their behaviour than non-ethicists. A survey of academics in the US reveals that philosophers do not think that their peers specialising in ethics behave any better than those who do not study ethics. Self-described ethicists condemn meat-eating more than their peers, but their actual eating behaviour appears similar to non-ethicists. And, paradoxically, more ethics textbooks appear to go missing from libraries than non-ethics books.

As Simon noted, there are some reasons to avoid jumping from this evidence to the conclusion that the study of normative ethics is of no help in the living of a virtuous and ethical life. But even if we accept that on average ethicists are no better citizens than anyone else, it seems that at least in some cases deliberation about ethical issues leads individuals to make decisions that are highly laudable.

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The ventilator lottery: rolling the dice in the face of difficult choices

As the winter approaches there has been a surge in the number of cases of swine flu, as well as a number of recent deaths in the UK. Although there is hope that the new vaccine will reduce the impact of the pandemic a number of countries including Canada the UK and the  United States have had to face the possibility that health services will not be able to accommodate the predicted surge in demand. Officials have been contemplating guidelines for deciding who should be prioritised for receiving life saving mechanical ventilation. The hope is that such guidelines will enable doctors to save the greatest number of lives in a pandemic.

But one concern about these guidelines is that they are unfair. Should scarce medical resources such as ventilators be allocated using a lottery instead?

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Premature death or wrongful death?

A headline in the Daily Mail from yesterday highlights the cost of over treatment for extremely premature and marginally viable infants.

    “Parents cause infant to suffer by forcing doctors to give futile treatment”.

Despite doctors counselling a set of parents that their 22 week gestation premature infant (born 4 ½ months early) had virtually no chance of survival, the parents insisted that Warren* be actively resuscitated and treated in intensive care and threatened legal action if doctors refused. Warren received chest compressions in the delivery room and was put on a breathing machine. He developed holes in his fragile lung and had multiple drain tubes inserted into his chest. Warren’s thin skin tore and broke even with gentle handling, and he developed patches of skin loss, like second degree burns, on his trunk and limbs. He developed bleeding in the centre of his brain, and on the 5th day of life perforated his bowel from infection. He died the following day. Meanwhile, 2 infants born prematurely in the same hospital were unable to be accommodated in intensive care because of lack of beds and had to be transferred to another hospital 1 hour away. One of those infants became unstable during the ambulance transfer and developed additional complications. Lawyers representing Warren are now considering legal action against the doctors and against his parents.

But of course, that wasn’t the real headline or case in the Daily Mail, and legal action such as that described is not likely to take place.

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The party line and the flu-line

It has emerged over the weekend that the UK government ignored the advice of a key panel of scientific advisors in the formulation of its pandemic response. The panel advised against the mass prescription of antivirals (Tamiflu) because of the fear that this would accelerate resistance of the virus (see also this previous post in the pandemic ethics series). An expert in influenza, Hugh Pennington, has even called for the national flu hotline to be shut down. It appears that the government may have been influenced in its pandemic response by political sensitivities.

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Pandemic ethics: Mild flu and Tamiflu – the patient’s dilemma

In recent days there have been reports of a jump in the number of cases of H1N1 influenza (swine flu) in the UK. There have been 29 deaths associated with pandemic influenza in the UK, and there are 652 people in hospital in England with the flu. Faced with the prospect of primary health care services becoming overwhelmed, the government has set up a telephone hotline to allow those affected by the flu to access antiviral drugs (for example oseltamivir or Tamiflu) without needing to see a doctor. But there are also suggestions that not all patients with flu-like symptoms should be treated. Patients with mild or vague symptoms of the flu, without other medical conditions that put them at particular risk, may not be given medication.

This sets up a problem for patients who develop mild flu-like symptoms. Although there is only a small chance of them becoming seriously ill or dying from the flu it is possible that early treatment with anti-virals would reduce that risk. (Antivirals were only effective in trials if given in the first 48 hours of illness) Should they demand treatment from their doctor in the hope of avoiding a serious complication of influenza? Should they exaggerate their symptoms? If the doctor refuses, should the patient self-treat with medications that they have obtained privately (for example over the internet)? There is a form of the classic prisoner’s dilemma involved in such questions.

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How much should we care about MPs’ expense claims?

Few people
in the UK could have missed the furious storm about MPs’ expense claims that has dominated the news headlines for the past several weeks.  A steady flow of stories has revealed not
only which MPs bent the rules on expenses, but also that many of the rules are themselves objectionable and arguably
facilitate a misuse of taxpayers’ money.

Of course,
few of us enjoy paying tax, but most of us grudgingly accept that it is
necessary if we want certain social goods like decent healthcare and a fair
justice system.  None of us likes to
think of our money instead being directed towards those who already enjoy a
higher income and better job perks than we do. 
What is most striking about the current focus on MPs’ expense claims,
however, is the fact that we are in the middle of a serious recession. 
And the amount of taxpayers’ money used to finance MPs' bogus
mortgage payments, luxury goods,
and furniture is but a drop in the ocean compared to the financial losses suffered by
homeowners due to falling property prices, by the half-million workers who have lost their jobs in the past nine months, and by those still employed whose tax payments must help support the newly jobless.  Given that the impact of a recession on
ordinary people is at least partly the result of government decision-making,
why does the recession consistently take second place in the headlines to the
relatively trivial matter of MPs’ expense claims?

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Life or no-life on the ventilator: the argument from parental freedom

In the High Court this week, parents of nine-month old infant OT are fighting a request by doctors to turn off the infant’s life support. The infant has been on a breathing machine since 3 weeks of age, and apparently has severe brain damage. This case has obvious echoes with the highly publicised case of Charlotte Wyatt, and the earlier case of baby MB. In both those instances courts ruled in the parents’ favour and life support was continued.

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