Post-Brexit healthcare from the UK’s National Health Service (NHS) has been under continuous burden as a nearly exponential demand in patients and a diminishing supply of resources persists. In the midst of consistent pressure to deliver quality care with limited funding and lingering debt from previous overspending, the NHS has not set national standards for reform. Just recently, and nearly two months post-Brexit, The Guardian covered a shocking decision made by a local, clinical commissioning group (CCG) within the broader NHS system to alleviate healthcare pressure using a blanket ban. From this point forward, all clinically obese persons, individuals with a BMI of 30 or over, will be denied elective surgeries for up to one year in the Vale of York CCG (1).
Does this decision exercise appropriate principles of justice in biomedical ethics? Furthermore, what are the consequences of these measures? One result is clear - the decision did not come without criticism. President of the Royal College of Surgeons (RCS), Dr. Clare Marx, heavily denounced the Vale of York’s action as one of the most precarious decisions made in the present-day NHS (1). Dr. Marx further stated that the RCS is not only in support of aiding clinically obese patients in their desire for speedy medical interventions, but also that “[delaying] patients’ access to what can be life-changing surgery for up to a year is wrong” (1). One NHS bariatric surgeon, Dr. Shaw Somers, described the Vale of York’s denial of elective surgery to clinically obese persons “like discriminating [against] a segment of the population on the basis of their colour or religious persuasion,” markedly because obesity is a medical illness (1).
Despite clear contentions, the Vale of York stood by its decision. The CCG argued that its recent mandate was necessary for optimal healthcare services given the stringent availability of resources (1). The NHS maintains the decision because the CCG is still within its legal right to pursue such an approach. While the NHS emphasized that further review should be taken, an NHS spokesperson did advocate for the possible outcomes of the CCG’s move: “Reducing obesity and cutting smoking not only benefits patients but saves the NHS and taxpayers millions of pounds” (1). In the end, the driving factor for the Vale of York is to distribute the maximum amount of services for as many patients as possible within their limited capacity.
Yet, will the end justify the means? According to Tom Beauchamp and James Childress’ Principles of Biomedical Ethics, conflicts in distributive justice and allocation of goods and services in times of scarcity is a healthcare issue that has transcended all generations and borders (2). Moreover, inequalities in healthcare access raise important questions about the justice of decisions made by policymakers for the public good. In the case of the Vale of York’s decision to deny elective surgeries to clinically obese persons, a strong utilitarian theory of justice was applied by the CCG. Beauchamp and Childress highlight the definition and purpose of utilitarian justice as a means to maximize net social utility and form healthcare policies that are based on cost-benefit or risk-benefit analysis (2).
Utilitarian justice has major advantages for the Vale of York CCG in a post-Brexit NHS. One idea that utilitarian justice might not consider, however, is the fair-opportunity rule of Rawlsian theory. As an example of egalitarian thinking, the fair-opportunity rule stresses that individuals should not be denied social benefits because of undeserved, disadvantageous conditions for which they have no control (2). An enlightening view of this theory offered by Beauchamp and Childress says that the intrinsic properties given to individuals by the social and biological “lottery” of life cannot be discriminated against in “social allocations if people do not have a fair chance to acquire or overcome these properties” (2).
Since obesity is a medical illness, which is linked to a myriad of genetic, environmental, economic, and societal influences, should the fair-opportunity rule not apply to the decision made by the Vale of York (3)? If the answer were yes, then the connection between denying clinically obese persons standard access to elective surgeries based on the condition of their illness would classify as an unfair discrimination. Some might argue that without a strong utilitarian mode of justice, then the already limited NHS resources and funding would plummet.
In response, I pose another scenario in which other CCG’s across the NHS uphold decisions to deny access the healthcare options to clinically obese persons. When access to healthcare becomes increasingly scarce for those populations of patients, is the interest of the common good truly being served to its maximum capacity? If we allow blanket bans to prevent or give lower priority healthcare access to those with intrinsic, disadvantageous conditions for which they have no control, then who will face unfair discrimination next?
References:
1. Beauchamp, Tom L., & Childress, James F. (2009). Principles of Biomedical Ethics. New York, NY: Oxford University Press.
2. Rawlinson, Kevin, and Chris Johnson. (2016, Sept. 3). Decision to deny surgery to obese patients is like 'racial discrimination'. The Guardian. Retrieved from https://www.theguardian.com/society/2016/sep/03/hospitals-to-cut-costs-by-denying-surgery-to-smokers-and-the-obese
3. Why People Become Overweight. Harvard Health Publications. Retrieved from http://www.health.harvard.edu/staying-healthy/why-people-become-overweight