03 February 2008

The power of life or death

Extracts from The Power of Life or Death (revised edition, 1999), pp. 183-186, emphasis added.


Considering now collectivised medicine, the question confronting those who are in favour of it ... is how allocation decisions should be made. ... Either such decisions can be made on such bases as first‑come first‑served or random selection. Or we arrange for someone else to play the role of arbiter, deciding on some ‘rational’ basis such as ‘quality of life’, or likelihood of success of the treatment, or usefulness to the community.

What is certain is that the arbitration option will generate endless discussion of who is to make the decisions, how they will be appointed, to whom they will be answerable, and what principles they are to apply in deciding.

Surely all users of such a service, including the most unsophisticated, should be clearly and unequivocally warned that they may find themselves in a situation where their wish to live is being weighed up by a committee. It is one thing for a person to be told (truthfully), ‘we are sorry, our resources do not stretch to providing the treatment you urgently require’; it is quite another for that person to be refused an available resource because he is considered unsuitable, whether or not he is told the reason for refusal.

Clients have a right to be warned that they may be denied available life‑saving treatment, and that this may happen for reasons that have nothing even notionally to do with their best interests. A large sign in front of all NHS hospitals, pointing out the serious dangers of relying on state medicine, might do for a start. If people are to be warned incessantly, at the taxpayer’s expense, of the risks of smoking cigarettes, they should certainly be educated about the more invisible risks of relying on a medical system which may choose whether or not to accept any given client.

Ethical principle

What those relying on a state health service [as opposed to those paying for medical services directly] should be able to demand is obviously debatable. Individuals should however be given full (and reliable) information about what they may or may not expect such a service to provide under various circumstances, and they should be told this early on in their lives, to enable them to make appropriate planning arrangements, and also to exercise what democratic power they have in determining what the rules will be for future generations. Clients must be warned about any limitations of the service, and in time for them to respond. Explaining to someone with a fatal condition that the NHS does not supply smokers is obviously not an example of a warning given in adequate time.

An ethical principle which I have not seen any professional (i.e. state-sponsored) 'bioethicist' enunciate. And one which, clearly, has been completely ignored and evaded by both the government and the medical profession.