Abstract
This article argues against the proposition that people should be denied medical treatment on the basis that they are responsible for their ill health. While it accepts that people can cause their own ill health, it argues that NHS staff are not in a position to determine the extent to which a person can be said to have contributed to their ill health in a blameworthy way. Further, that ill health is often a result of multiple causes, and it is unfair to isolate the patient to bear the costs. The article concludes by promoting a vision of relational health whereby we recognize our responsibilities to produce healthy communities and relationships.
Introduction
The articles in the first part of this issue have explored the theological understandings around responsibility for health. This article will explore a practical application of these debates: whether patients’ fault should be relevant when making rationing decisions.
Some public voices certainly think that people who have caused their own ill health should be denied treatment. Amanda Platell, a journalist, writes: Could you ever have imagined an age in which young mothers dying of breast cancer would literally have to fight to the death to be given the drug Herceptin, while obese women have access to stomach-stapling operations, anti-obesity pills, gastric bypasses and any other weight-loss ‘cure’ that takes their fancy, all on the NHS?
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The National Institute for Health and Care Excellence (NICE) provides clear guidance that fault should not be relevant in deciding what treatments should be provided by the NHS: NHS care should not depend on whether people ‘deserved’ it or not. NICE should not produce guidance that results in care being denied to patients with conditions that are, or may have been, dependent on their behaviour. However, if the behaviour is likely to continue and can make a treatment less clinically effective or cost effective, then it may be appropriate to take this into account.
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The case for taking fault into account
The argument in favour of taking fault into account is that we should be responsible for the consequences of our decisions. It has been claimed that of the ten leading risk factors causing disease seven are a result of ‘unhealthy’ living including tobacco, alcohol, low levels of activity, inadequate quantities of fruit and vegetables, and the like. 3 If people make choices to behave in a way that causes themselves serious harm, then they should not expect others to meet the costs of that harm. At the very least, it might be claimed that, if we must choose between allocating a limited resource (such as a donated kidney) between one of two people, we should prefer the person who is not to blame for getting themselves in such a condition. The person who has lived healthily may argue that it was the other’s unhealthy choices that have created the dilemma over what to do with the kidney. Alternatively, the state might reasonably conclude that any person who undertakes risky activities should be expected to pay for the costs that arise; this could be organized through taxing the activity. 4
The concept of responsibility for ill health is explored theologically in the first part of this article. The belief that ill health could be a punishment for, or at least a consequence of, sin is a theme of Christian theology as Katherine Southwood’s discussion indicates. Indeed, such an approach is not unknown in healthcare law. In private health insurance the premiums that one is asked to pay will be based on the assessment of the risk based on the prediction of how one is likely to behave. Yet in terms of a nationalized health system, such as the NHS, neither of these arguments seems to apply. A person who lives an unhealthy lifestyle is not expected to pay any more for their healthcare, nor will they be denied healthcare or charged for it where their medical condition is a result of their fault.
I suggest three arguments for why it is appropriate that, in public health decisions, the fault of patient is not taken into account.
The problems in judging responsibility
As Joshua Hordern notes in this issue, the allocation of cause and responsibility for ill health is ‘very difficult’. This difficulty has many aspects.
First, disease can have multiple and complex causes and rarely can be seen as straightforwardly solely the fault of the patient. Was the heart failure due to the patient’s unhealthy eating or due to stress or due to genetic weakness in the heart? In many cases, a combination of individual choice and social factors combine to create the conditions for the disease. Second, in so far as a patient may have contributed to their ill health, they can only be held to account if they had sufficient awareness that their choices would result in their ill health. Yet messages about how to live healthily can be conflicting and confusing. Third, generally people are only responsible if they have the freedom to make that choice. That is complex. We do not know the extent to which social pressures, socio-economic background, peer pressure, family influences and so forth impact on decisions around food consumption or alcohol intake, to take two examples. Finally, even if a person has knowingly acted in a way that has caused themselves ill health, we would not blame them for that choice if that choice were seen as a praiseworthy one. For example, someone caring for a relative with dementia who becomes depressed or a pregnant woman who gets pre-eclampsia would not be seen as blameworthy even if, in one sense, they had brought the condition upon themselves. But the assessment of what kinds of ill-inducing behaviour are appropriate is complex.
The difficulties of judging
Even if we were to assume the problems outlined could be overcome and it was, in principle, possible to determine the responsibility of the patient for their condition, it is impractical to expect NHS staff to determine responsibility. As will be clear from the discussion in the previous section, a healthcare professional is not in a position to make the kind of assessment of whether the patient is appropriately responsible for their behaviour to be denied treatment they would otherwise receive. It would be particularly difficult to do so in a way that was not highly invasive of a patient’s privacy and may lead to patients not being open with their doctors about their symptoms or behaviour for fear of being found at fault.
The responsibilities of others
There is also a difficulty if patients are held to be responsible for harms to their health but other bodies are not held responsible for their contributions to the health of the public. Politicians whose economic decisions cause ill health, advertisers and sellers of unhealthy products, sellers of alcohol – all these could be seen as responsible for causing ill health but are not held to account directly for that. While there can be limited sanctions in certain situations, such as polluters and producers of unsafe products, prosecutions are rare, the punishments tend to be limited and they are certainly of a different scale to that faced by a patient denied medical treatment.
Relational medicine
I will argue in this section that the argument for responsibility presents an overly individualized understanding of the self and our health.
Our health and our bodies must be understood in a social and relational sense. We are mutually vulnerable and interdependent. But that weakens the argument for individual responsibility. Health is best understood, I would argue, as a communal, relational thing. 5 We take too narrow an understanding when we emphasize individual assessments of and responsibilities for health.
Harald Schmidt refers to the finding that a boy growing up in the Glasgow suburb of Carlton will have a life expectancy of 28 years less than a child born in nearby Lenzie (54 as opposed to 82 years).
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Meredith Schwartz’s review of the evidence concludes: There is significant evidence that health inequalities exist between members of socially privileged groups and members of socially disadvantaged groups such as the poor; racial, ethnic or indigenous groups; women; people with disabilities; homeless people; and lesbian, gay, bisexual, and transgendered individuals.
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The healthcare professional then shifts from seeking to allocate blame to seeking to find ways of improving patients’ health. This model sees health as a communal activity and responsibility. This certainly requires the parties to contribute to the system as best they can and a duty to do what can be done to behave responsibly. The responsibilities of the state to enable people to make reasonable choices, to provide healthy environments and to promote caring relationships are taken seriously, indeed more seriously, than individuals’ responsibilities for their health.
Conclusion
In this article I have argued that the conditions which would need to be satisfied before a patient can be held to account for their state of health are rarely met. In any event, healthcare professionals are not in a position to make that kind of assessment in deciding whether treatment should be given. However, there is a more fundamental objection. The suggestion that we should deny treatment to patients based on their fault misunderstands the true nature of health. We are a collection of vulnerable people. Few people make all the right choices for their health. Our health is interdependent on those around us, in relationship with us and on our wider environment. Rather than blaming people for their ill health, we would be wiser to spend our efforts promoting healthy communities and relationships.