Rationing and Rationality in the Health Service

The rationing of health provisions is something that garners considerable controversy, so I felt it would be worthwhile to go into it in more detail.

As you’ll know, the NHS is a publicly funded health provider, with finite resources to treat and care for patients. However, if the very best interventions were used for every patient, the NHS would need many times the funding it currently receives. As a result, something has to give, and certain drugs, procedures and care elements must be withheld to stay within budget. The billion-pound question is how the service should be rationed – what should be provided, and to whom.

Intuitively we might be lead to a simple cost to benefit ratio system. Each treatment could have the years of life, or better still years of life adjusted for quality, compared with its cost. This could give a simple value of the cost per year of healthy life. However, it cannot be so simple, in part because the use of one treatment may in time lead to far more expensive care for an illness in later life, such as dementia. A doctor I shadowed during the Summer actually suggested that, if the NHS wanted to save money, they should encourage people to smoke so that people died from acute rather than chronic diseases.

Ignoring the indirect effects for now, here’s an example: A Primary Care Trust (or soon to be Clinical Commissioning Group) has a portion of its funding left to spend, and has two options. It can provide statins to all those with moderately raised cholesterol levels thus reducing the risk of vascular or cardiac diseases slightly for each individual, or artificial dialysis for all those in renal failure, which is clearly saving lives directly.  Both cost the same, but spending the money on providing statins has a cost per healthy year of, say, £10,000, whereas the figure for dialysis is £20,000. This situation is simplistic and ignores the side effects of both, and the figures are made up but not far from reality. In this context ‘Statins’ could be replaced with any risk-reducing, preventative or early diagnostic measure, and ‘dialysis’ with any direct intervention with a greater cost to benefit ratio.

If we were only to use a simple ratio we would consign those in renal failure to certain death in order that a much larger number of people will have only a slightly reduced risk of disease because the net benefit is greater if we provide statins. However, this seems intuitively wrong to us, and the potential recipients of the statins would likely prefer that the money be spent on providing dialysis rather than giving them an insignificant reduction in personal risk.

This is known as the ‘rule of rescue’, that we see ourselves as having an ethical prerogative to save an identifiable person, even if the resources put into it would be better used on what could be termed ‘statistical’ people. The term comes from the enormous resources that are often put into finding a missing person, or rescuing one in danger. You may have noticed that, to quite an extent, this is how the NHS functions, with things like intensive care units, expensive ‘last-ditch’ cancer drugs, and arguably many surgical procedures. In other words, prioritising care to people who require it immediately at the expense of people who could have their risk of disease reduced. The fact remains that those ‘statistics’ are still people in need of healthcare, and that their eventual illness and death is just as real as the individual’s. The rule also acts the other way - patients believe, rightly or wrongly, that they are entitled to certain treatments. This can be very difficult for doctors if the expected treatment is not within guidelines.

The ethical dilemma of a cost to benefit ratio is deepened when we consider groups such as the users of tobacco, the overweight, the elderly and other at-risk groups. It seems reasonable that the future prospect of life, which is often limited for, say, the elderly, should also be factored into healthcare rationing decisions. The practical implication of this would be that that the prior-mentioned groups may have certain treatments withheld on the grounds that they will get less benefit than a young, healthy person would. This runs against our intuitions about the need for equality in healthcare provision, and again for providing care to those who need it immediately.

In an ideal world we should want to help all groups of people, be they identifiable individuals or ‘statistics’, and be they young or old, but we often aren’t able to do so. In these times of economic trouble, perhaps we have an imperative to move from the ‘rule of rescue’ to a more holistic provision of healthcare which has greater emphasis on prevention and early diagnosis, lest the service run into such financial difficulties that it cannot adequately provide either. By the way, this is not a manifesto to stop dialysis or shut down ICUs, but simply something to get people thinking about how healthcare is rationed, and whether some parts of the NHS may have become too bloated at the expense of simpler preventative intervention.

So, do you agree with my tentative conclusion? Do we base too much of our health policy on the rule of rescue at the expense of healthcare? Where should we draw the line between expenditure on public health and on treatment?

- Daniel

Resolving The Trolley Problem

In the discussion of ethics, analogies and thought experiments are often used to support a certain viewpoint, or to test an ethical approach. A thought experiment often used to elucidate the difference between consequentialist (the ethicalness of an action is based on its ultimate end) and deontological (certain things [e.g. killing] are wrong, regardless of the situation) positions is the 'Trolley Problem'. I'll look at the original problem, and then at two interesting modulations of it.

The Original Trolley Problem

The dilemma goes like this: A train is heading full steam towards a two-way junction, and there's no time to engage the break. The train is currently set to run over 5 workers repairing the track, and there's no time to warn them. On the other arm of the track is a single worker.

You happen to be standing directly next to the lever that can be pulled to change the course of the train, killing the one worker instead of the five. What do you do? Which is the most ethical course of action?

The choice from consequentialism is clear: You must pull the lever for the greater good, saving five lives at the expense of one. However, an ardent proponent of duty-based ethics would most likely not pull the lever, as to change the course of the train would be equivalent to murder.

This raises some interesting issues and problems with both positions. While leaving the train to take its present course will result in the deaths of five people, changing the direction of the train (an act) will be certainly be equivalent to murder, even if it is for the greater good. Would leaving the train (an omission) be the same as murdering five people. This is the fundamental problem of acts and omissions, and whether there is any ethical distinction between the two. This is something that you will have a personal view on, mine being that there is no distinction between the two; if you are in a position of responsibility, to allow something to happen is equally bad as consciously doing something that will have the same effect.

The Bridge

One interesting change in the original problem is to have, instead of a single person on a branch of the track, a man on a bridge, that you can push off to save the lives of the five.

It's likely that this situation will have evoked a greater emotional response, even though both situations are essentially the same in terms of possible outcomes: Either five people will die, or one will die. Where does this difference come from?

One possibility is that, in the first instance, the death of the one person was intended (i.e. the train would not have run over the five people, even if there was no person on the other track). However, in this situation, the death of the single person is intended to save the lives of the five. This is the principle of 'double effect' - that while there are two results of the action (the death of the single person, and the survival of the five), in the original scenario the death of the one was unintended (but foreseen), while in the second the death was both intended and foreseen (to save the five).

Is there any difference between the situations? In terms of ultimate eventualities, no. However, there is still something that evokes a different response, and it is hard to put our finger on it. In part, it could be the simple fact that the death of the one person was unintended in the first, but intended in the second, as alluded to earlier. I believe that there may be something more to it though; that part of this is relating to the person in control of the situation.

People often give each other similar options between two undesirable events (would you rather do x or y?) Perhaps some of our opinions on the trolley problem stem from an empathising with the person who must make the decision. In the first situation, the person only needed to pull a lever to change the situation, simply changing the direction of the train. However, in the second, the person must physically push an unsuspecting person into the course of the train to stop it - a prospect that no one would like to face.

In summary, the distinction between the two scenarios comes from the nature of the act designed to avoid the worst eventuality. The difference comes, in my opinion, from the intuitive contrast between acts and omissions, and in part from our relating to the decision-maker. I've no doubt that you will have different opinions on the situations, and on whether there is any moral difference between them, and what the nature of this difference is.

The Surgeon's Dilemma

I will now present one final ethical dilemma. A surgeon has five patients who are all going to die within the week if they aren't given an organ transplant. Unfortunately, there are no suitable organs available for transplant, so are all certain to die very soon. However, there happens to be another healthy patient recovering in a nearby ward who happens to have all of the organs required.

I would be surprised if you were not very strongly against the killing of the healthy person, yet this situation is technically no different to that of pushing one person off the bridge to save five. There is, however, a few subtle difference that I think may be responsible for this disctinction.

The first is an intuitive 'slippery slope' argument - most people know that there is a shortfall in organs to be used in life- saving transplantation. If we assumed it ethical to kill the healthy patient to save the five, it follows that this should be done whenever the situation arises, hence leading to deaths of hundred, or thousands, of healthy people every year to satisfy demand. No person with any sense of morality would see this as a desirable state of affairs, so we naturally reject the original case.

The second is that, although the scenario specifies that a particular patient has the required organs, and that the five requiring the organs will die if they don't receive them in the next week, we may automatically think of other scenarios. Unlike the trolley scenarios, where there could only even be two options, the matter of organ transplantation has other options in the longer-term: Opt-out organ donation schemes, use of animal organs, transplantation from live donors (e.g. a kidney or lung), and even the harvesting of organs from the deceased who haven't given permission. In summary, the presence of better possibilities, even if not in this specific case, could also cause us to be outraged at the possibility of organ harvesting from the non-consenting living.

Daniel

Are Soldiers Heroes?

“All wars are civil wars, because all men are brothers. Each one owes infinitely more to the human race than to the particular country in which he was born.”

This is a controversial topic that I have wanted to summarise my thoughts on for some time, and my answer to the question posed is 'no'. To clarify the meaning of the title, by 'soldiers' I mean people who fight in an army as part of their job currently, and by 'not heroes' I mean not possessing the qualities of a hero by virtue of being a soldier. I will first summarise why soldiers should not be considered heroes, then tackle the 'pro-hero' arguments, and finish by discussing the potential dangers of the hero worship of soldiers.

Why Soldiers are Not Heroes

The crux of my argument lies on the nature of a soldier's job; this being that, amongst other things, the primary job of a soldier is to kill others as part of a war. This is an inescapable fact, and a fact that people often forget or ignore, unconsciously or wilfully. This is my first premise.

My second premise is, to some, less easy to accept. This is that killing is a fundamentally immoral activity, unless it is done as an absolute last resort in self-defence or the defence of another. You may be thinking that this is the perfect description of the reasons that soldiers kill, but on closer examination it is not. Soldiers have made a concious decision to join the army, and have allowed themselves to be shipped out to whatever country they are now in, and accepted the orders to kill another human being. They have not been conscripted or otherwise forced, and have had the chance to not take part at many occasions.

It follows that the job of the soldier is an inherently immoral one, and that whatever individuals may do to exceed themselves, it doesn't negate this fact. It is true that soldiers can do heroic things, like throw themselves onto grenades to save their comrades, but this does not make all soldiers heroes, and does not necessarily make the individual a hero outright - as an analogy, imagine a Taliban fighter doing the same thing, of throwing himself over a grenade. Would that make him a hero, even though he has been a member of a horrifically violent and amoral fundamentalist group? The example is extreme, but apt nonetheless.

Perhaps a very small number of soldiers could be considered heroes by virtue of their actions, but note that these actions would almost certainly not be of a violent nature, and that non-soldiers also perform acts of equally laudable heroism without the civilian groups they are part of being considered as comprised only of heroes. To call all soldiers heroes is an absurdity (unless killing is much more acceptable to you than I) and dangerous, as I will come to later.

Debunking the Counter-Arguments

The argument most often put forward for the heroism of soldiers is that, without them, we would not be speaking English/not living in England/not be alive, and so on. Not only does this argument not apply to any conflict for the last 70 years, but it ignores that pacifist position that all are undesirable - not just the British one! I won't comment on whether the soldiers of WW2 are all (or most) heroes, as it's a complex and difficult issue that I dare not try to tackle, but the fact remains that soldiers currently fighting in Afghanistan, and Iraq until recently, are not 'defending our nation' in the profound way that some suggest.

Another similar, and even more vague, argument is that without soldiers we would not have freedom, and that I would not be able to profess these 'disgusting' views. Perhaps if we, again, go 70 years back this may have some truth. If anything, wars have damaged freedom, causing an approximate seven-fold increase in terrorism since the invasion of Iraq, which has led to a reduction in freedoms since the implementation of domestic policies to combat terrorism. I won't give more than a sentence to the argument interchangeable with this; that soldiers are 'defending our country' - a ridiculous claim for any recent conflict on the face of it (Taliban ground invasion anyone?).

I will try to deal with the other minor arguments in this paragraph by use of analogy. Take a typical Taliban fighter. The chances are that he is not bent on 'Global Jihad' or terrorism, but instead considers it to be his duty to fight against foreign invaders. Surveys have shown this to be true, with a majority fighting with the, perhaps misguided, intention of defending their country, and a very high percentage having lost a close relative to the conflict. It is therefore comparable, in that a majority have (perceived) noble intentions, much like for NATO soldiers, a  very small minority of whom doubtless have extreme Islamaphobic  attitudes, or are in it for the sake of being able to kill people. Note that this person is actually putting themselves in far greater risk than a NATO soldier, as he statistically has a much higher probability of being killed.

On almost all levels, the Taliban fighter and NATO soldier are much the same, if any particularly heroic (and uncommon) actions are not considered. Do we call them both heroes? I don't know about you, but I'm not in the habit of calling members of brutal fundamentalist groups heroes, so it is more reasonable to call neither heroes. It is what people do that matters - not what they are, or what they intend to do.

Why Hero-Worship is Dangerous

“War will exist until that distant day when the conscientious objector enjoys the same reputation and prestige that the warrior does today.”

I hope that I have convinced you that not all soldiers should be immediately named as heroes, but if not, and even if I have, you may still ask what the harm is, if it helps support the soldiers and their families (both of which I do sympathise with very much!) The answer is that the universal praise of soldiers is the beginning of a dark path to the acceptance of violence and killing.

If we consider killing to be acceptable (never mind laudable!) if it is done with the 'good intentions' of war, or that it is not immoral if the person being killed has been judged to be evil and undeserving of life by his membership of a particular group alone, then we have become, in the absence of an alternative word, much like Nazis, even if these groups are deserving of hatred. If we demonise a group to such an extent (not that the Taliban or Saddam Hussein's regime etc. should not be demonised) that the people who fight, injure and kill its members are to be worshipped as 'heroes', and anyone who says otherwise is attacked so voraciously, then we are no longer a civilised society that values the life, equality and justice that many claim soldiers are actively defending.

Perhaps even more dangerous is that hero-worship detracts from tackling the true reasons why war, and specific wars, happen. Burying these reasons in a tide of patriotism, and excusing the belligerents (at all levels) because they have ‘good intentions’ runs the risk of creating a society that is apathetic to violence, and uninterested in peace. It is time that we looked up to the conscientious objectors – those who have inquired about what they are truly fighting for or against, and have risked punishment and ridicule for doing what it right, and refusing to play a part in organised homocide.

- Daniel

Why are we good (at least sometimes)?

The penultimate introductory piece is ethics, and it's a discussion of the biological and cultural roots of morality. Although this doesn't relate directly to any ethical debate, and is more a scientific topic than an ethical, it is an interesting topic that's worth spending some time on. The article is split into two sections: The genetic/evolutionary roots of morality, and the cultural roots of morality.


Biological Roots

Family Values

Imagine that you are a gene (as in a length of the DNA that lasts long enough to be evolutionarily significant [not necessarily coding for a single protein]), as unusual and difficult a request as that is. Now imagine that your main aim is to survive for long enough to be replicated (in humans through sexual reproduction). You also have a secondary aim; to help exact copies of yourself - for example, the ones your organism views as sibling and parents each share around 50% of your own organism's DNA, so have a 50% chance of having 'you'. Remember, you're just a sequence of bases, and are unable to directly influence the environment, but you are able to code for the physiology and psychology of the organism you are a part of - the real you! By giving your organism certain traits that other organisms might see as 'moral', and indeed other traits that could be seen as 'immoral', you can ensure your survival, and the survival of those who are likely to possess a replica of yourself.

This is a grossly simplified and anthropmorphised thought experiment. Your genes can no more select your characteristics than you can select the weather tomorrow, but over enormous lengths of time there is a process by which your genes can gain control over your characteristics - evolution. More precisely, evolution selects those genes which code for evolutionarily advantageous trait. Those organisms with 'bad' genes, both physiological and psychological, will die out, and those that have 'good' genes will flourish. For example, we can assume that a mutant gene that gives an organism an insatiable desire to slaughter all its relatives will not remain in the gene pool for very long. On the other hand, a gene that makes the organism a selfless being which lives purely to serve others and expects nothing in return will also exist for the briefest moment on an evolutionary timescale.

Now that you've been given a background, it's time to go back to the issue at hand. Why do we feel an innate empathy for those who are closely related to us (as well as partners), and will invest our time and energy for them even if we expect absolutely nothing in return - what most know as love. As I alluded to above, we share around 50% of our genetic material with immediate relatives, and smaller percentages with more distant relatives. From an evolutionary perspective, it makes sense that the human mind is geared towards wanting these relatives to survive and reproduce as well, as a gene that gives us a sense of family altruism will be very successful. It's worth spending a couple of minutes trying to get your head around this idea, as it is important to the rest of the article and is profound in its own right.

Evolution favours genes that produce organisms that invest time and energy into other organisms that are likely to share the same gene. This creates a self-reinforcing cycle - the reason why almost every animal has been observed to help out its family.


Reciprocal Altruism

So we've looked at the roots of family altruism, but the vast majority of people we meet aren't related to us. Why is it that we ever help out non-related people, and why do we expect them to help us?

In short, this is a case of "You scratch my back, I'll scratch yours". Seemingly altruistic acts are often carried out with the expectation of a return in the future from the person benefiting. I know how cynical that sounds, but in many situations it turns out to be true, even if we don't realise or want to accept it. As I mentioned earlier, genes that coded for an organism that would provide help at the expense of its own chances of survival would quickly die out, as the organism would be vunerable to exploitation to what we can call 'cheaters', who accept the saintly organism's aid but give nothing in return.

However, there's still hope for humanity! People could not be entirely selfish/exploitative. While genes could code for an organism that will only receive help without giving any in exchange, the rest of the population would evolve to identify cheaters, and evolve a mechanism against them, such as grudge holding if they don't return favours. Technically a small number of selfish organisms (or people) could exist, but it's unlikely that they would come to dominate the population.

The genetic roots of morality apply more to other animals than to humans, for the simple reason that we have evolved something unique - a brain that can make complex decisions for itself. We have moved beyond our genetic pre-programming to establish a higher, and occasionally a lesser, morality.

I should point out that most of the post so far is a summary of Richard Dawkin's 'The Selfish Gene' - a fantastic book that you should definitely read!


Cultural Roots

 Memes

It has been proposed that a new, more rapid type of evolution has taken over where evolution left over. Instead of genes being propagated through the generations, there are now ideas or 'memes'. While genes use the organism as a host, and reproductino as a means of self-continuation, memes use the human brain as their host and the transmission of information (word of mouth or writing for most of human history) its means of continuation.

Just like genes, 'bad' memes, or those that are not memorable, relateble or useful, will die out, and the 'good' memes will survive and spread. An example of this is religion. Religion gives answers to deep and troubling questions about reality, as well as providing the possibility of good things in the future when the present is full of suffering. As a result, it has become a particularly successful meme, survivng for millenia and held by billions around the world. Likewise, ideas such as nationalism, racism, charity and countless others can come to be widely held if they are successful memes.

The other cultural sources of morality or immorality are well-known, so I won't waste your time telling you about them. These include religion, family, friends education and media, and probably many more that I haven't thought of.

Nature vs. Nurture

In the end, this entire issue of the roots of morality boils down to the classic nature vs. nurture debate. It's certain that both play important parts, but we may never know which has the greater role, and the discussion of it is beyond the scope of this post (but maybe I'll spend some time looking at it in the future!)

I'll leave you with a couple of things to think about:

1. If a person was seperated from other people from birth, and every man-made thing and piece of information (i.e. no culture whatsoever), would they see murder as inherently wrong?

2. If a person was taught from the age when they could first absorb information that murder is inherently good (not just the 'better of two evils', but a highly moral and righteous thing in its own right), and were not exposed to any information that would conflict with this (i.e. culture overload), would they come to believe that murder was a truly good thing?

Feel free to leave your opinion on these questions in the comments below.



- Daniel

Introduction

So, this is my blog. I thought I should probably give a little introduction to myself, and to the blog.

As you can see from my personal information to the right, I'm a sixth-form student living in the UK, with a keen interest in Science, Technology, Ethics, Philosophy, Politics and Sociology (S.T.E.P.P.S, if you hadn't worked it out yet). I study maths, biology, physics and chemistry for AS level, and hope to go into medicine after leaving school. So that no one reading this is under any illusions, I'm a humanist and a socialist (deal with it!) Now I'll give a introduction to the different topics covered by my blog:

Science: Science (from Latin scientia, meaning "knowledge") is a systematic enterprise that builds and organizes knowledge in the form of testable explanations and predictions about the universe (shameless Wikipedia copying and pasting, I know). But there's more to science than that.  It is, as far as we know, the best tool for understanding everything in our universe, from the quark to the galaxies, and from the virus to that most wonderous of things; the human brain. Science is the basis of almost everything that we take for granted in our technical civilization, from light bulbs to the space shuttle. Without a doubt, science is the most important element of our humanity - the drive to discover, to explore and to better ourselves.

Technology: Technology, in short, is the application of science to design, construct and use tools (of widely varying complexity) to perform a specific function. When I talk about technology, I don't mean the gadgets that various companies churn out (ehem... ipods, iphones...) that add little to our lives (apart from fun of course!), but the technology that can help us to grow food, to travel around our planet in a matter hours, or to explore the universe. I'll look at the technology that really adds something to our society, and especially important emerging fields of technology, such as nanotechnology and the development of artificial intelligence.

Ethics: Ethics is a branch of philosophy that is used to decide what is considered 'moral' or accpetable to do. It's a wide-ranging topic, covering issues from justice and crime to animal rights and medical ethics.

Philosophy: Philosophy is, as I like to think it, the waiting room of science. It is the place for questions that we can not yet answer using our preferred method, science, but that must wait for perhaps hundred of years, or may never be fully answered. It's the place of the really big questions that make your head hurt if you think too long about them, like "What is the meaning of life?" (other than 42 [haha...]) or "Why are you you?" Philosophy has evolved considerably from its roots millenia ago, and has narrowed somewhat, as parts of it have moved out of its own realm, and into the realm of science. However, it still has many crucial, unanswered questions that are well worth considering.

Politics: *Yawn!* Yes, politics can be boring, espeically in our two-party state, vote-every-four-years media circus, where all the parties are continually at eachothers throats about everything. Accordingly, I'll try not to look at every tiny decision that various governments make, but more at the interesting trends in politics, such as the sudden rise of the far right, or what the global economy might look like after (and if!) it begins to recover.

Sociology: This is the one that not as many people have heard of. Sociology is, in short, the scientific study of society. This makes it overlap significantly with the other five topics, making it of particular interest to me. It deals with issues such as war, nationalism, racism and why no one likes gingers (no offence). I'll explore events, such as the summer riots, as well as long term trends, such as the decline of religion, especially in developed countries.

Other: I'll probably end up sticking in the odd book, film or game review, anything interesting that happens in my life (there really isn't much, trust me) or whatever else I feel like writing about.


Well, that's an introduction. If you'd like any more information about the blog,  would like to make any suggestions or would like to contribute an article, just comment (and please don't be too harsh on me - this is my first ever blog post...)

Also, apologies for the labels at the top being out of order. It won't let me arrange them as I want... If anyone knows how to sort them I'd be grateful for some advice.


-  Daniel