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November 01, 2005

Thankfully there is no justice to the allocation of medical care - if there were many of us would be left to die agonising deaths, argues Theodore Dalrymple

Posted by Theodore Dalrymple

Many of us can be extremely thankful that there is no justice to the allocation of medical care. Theodore Dalrymple - who has recently retired as a doctor - argues that, if justice were the basis on which medical care were provided, rather more of us than we might care to imagine would be left to die agonising deaths.

It is a curious, but very widespread, prejudice that if there were any justice in the world, we should all be better off: except, of course, for a small percentage of evil men (generally rich and powerful) who would be very much worse off, and whose justified discomfiture we greatly enjoy rehearsing in our imaginations.

Now if it were true that if there were any justice in the world the vast majority of us would be better off, the virtue of mercy would be quite unnecessary. Indeed, most other virtues would be redundant. Suffice it to say that the improvement in our lives allegedly to be brought about by the rigorous and strict observation of justice has not been in accordance with my experience of life, of my fellow-beings, or even of myself.

Still, the prejudice persists, and is to be found everywhere – even in the editorials of The Lancet. For example, in the edition of 8th - 14th October 2005, the following sentence appears in an editorial entitled The NHS – a national health sham, a sentence of which the editor was so proud that he printed it in large print on the front cover of that august journal:

To prevent potential dissolution, the governing principles of health-service reform – universality and equity – need to be more firmly reiterated.
Equity means fairness and justice to all, which is actually the last thing one wants from a health service. If there were fairness and justice to all, substantial numbers of patients would be left to die a miserable but well-merited death.

Let me give a concrete example. A heroin addict with a long criminal record of violence and dishonesty is found deeply unconscious and scarcely breathing because he has taken more than his usual dose of heroin. He is brought to hospital, where he is resuscitated with some difficulty by a dedicated and skilful doctor. When he wakes up, his first words to her are "Get us a fag, you bitch".

Surely it is obvious that fairness and justice required that this man should have been left to choke to death on his own vomit. It would have been much better for society, at least in a utilitarian sense, if he had actually done so. We should all have been a fraction better off.

Of course, I can already hear objections: that the man came from a very bad background, and that as an addict he was not in control of himself. But we all come from bad backgrounds, where the justification of our bad behaviour is concerned: has anyone led so easy and happy a life that he can find no excuses somewhere in his past for his present shortcomings? Besides, "bad backgrounds", as they are known, are promoted by the very idea that if there were justice in the world, we should all be better off, for such an attitude renders irrelevant our own conduct as to our fate in the world, at least in our own opinion. We delude ourselves into thinking that it is all the same whether we take heroin or learn foreign languages.

Addiction is not an adequate excuse for this man's behaviour, either, nor is it involuntary, as his apologists would claim. This is not the place to rehearse my reasons for saying so, but in my view they are decisive. The fact is that, throughout the world, there are millions of addicts to various substances, including heroin, who have given up their addiction by the process of taking thought.

Here was a man who brought only misery and expense to others, as far as a medical history was able to ascertain. His relatives had disowned him, and he had burgled and beaten his way into prison, despite the resistance of our criminal justice system to any such outcome. He had fathered abandoned children, who were a charge on the state (which is, of course, to say you and me), and he would in all likelihood father more children in his brief periods out of prison by women whom he would abuse. Unless you take a very forgiving Durkheimian view of his life, that he had contributed to the solidarity of society by becoming an outsider and an outlaw against whom it could express its collective disapproval, you would be forced to concede that this man had contributed nothing to society and had damaged it very considerably.

Is it fair and equitable that you and I should have to work hard in order to be able to pay taxes so that such a one's life might be saved in hospital? The injustice is patent, at least to me. As I have indicated, justice and equity required not the medical treatment of this man, but his death.

Nor is this case so very unusual, as a visit to the casualty department of any of our larger hospitals on a Friday or Saturday night will confirm. They are full of people who deserve to be left to suffer horribly as a consequence of their own vile or grossly irresponsible behaviour.

Does this mean, therefore, that I think all these people should be left to die, or to become permanently deformed and maimed as a result of their largely self-inflicted injuries? It does not follow in the slightest, because there are other reasons for treating suffering humanity than that it is only just that they should be treated, when clearly it isn't.

Kindness, decency, humanity, fellow-feeling, mercy and charity are all good reasons to abrogate the demands of justice in the casualty department of a hospital. For myself, I don't want a society in which a man, such as the one I have described, is simply left to die as he manifestly deserves. It would be a very cruel society in which justice was allowed to run its course.

Does it matter that The Lancet in its editorial adopted completely the - in my view - obviously wrong principle that medical care should be allocated on the basis of justice? Does it matter that The Lancet's editorial supposed - again, in my view quite wrongly - that the application of this principle would mean that we would all be entitled to exemplary medical care? Yes, I think it does; for this kind of preening self-satisfaction leads not only to very poor policy-making, but causes the behaviour of ordinary people to deteriorate. Let us, as Pascal said, try to think clearly, for such is the foundation of morality.

Theodore Dalrymple is a writer and retired earlier this year as a doctor.


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"Still, the prejudice persists, and is to be found everywhere – even in the editorials of The Lancet. For example, in the edition of 8th - 14th October 2005, the following sentence appears in an editorial entitled The NHS – a national health sham, a sentence of which the editor was so proud that he printed it in large print on the front cover of that august journal"

I can't be the only one to find the practice of the Lancet of printing some supposedly shocking but in practice usually rather trite sentence from some article or other inside on the front page deplorable. I much prefer the cover of a few short years ago, simply the contents of the journal reproduced verbatim.

On a more serious note, I think a useful study would be to take a whole year of Lancet editorials and ascertain what proportion are aimed at doctors and discuss, in some more or less direct way, the business of actual medical practice, and what proportion are in fact directed to "policymakers." And what proporion of said editorials are pleas to government to "do something" - indeed, what proportion directly plead for more state funding?

The Lancet has been disfigured beyond recognition by endless articles on various public health topics. One can almost hear the editor's boredom and exasperation with mundance medical topics like which antibiotic is best in such and such a case or a new technique for snipping off haemorrhoids - much more exiciting to come up with some pious article about the plight of "sex workers" or somesuch and hopefully a thundering editorial on same...

Posted by: jim mcqueen at November 1, 2005 07:44 PM
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One question. If we reject justice as the criterion for the provision of medical care, and resort instead to "Kindness, decency, humanity, fellow-feeling, mercy and charity", would this make a practical difference? If the individual discussed in the article were to return again and again, behaving with identical vileness each time, would there be an argument for refusing to treat him? Or would "Kindness, decency, humanity, fellow-feeling, mercy and charity" always come to the rescue?

Posted by: OD at November 1, 2005 09:56 PM
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Like the author, I have long puzzled over the endless quacking for justice when what virtually all of us should want is mercy. I suppose that appealing for mercy makes us realise that we are all sinners to some degree or another and leads thoughts of morality and self-improvement, while calling for justice helps one feel superior, sanctimonious and aggrieved and enhances greediness and those selfish thoughts which are so much more comforting. This maybe why socialism inculcates such pap about justice, as a kind of moral bribe to the riffraff. As ever, Dr Dalrymple provides us a splendid little essay.

Posted by: s masty at November 2, 2005 10:14 AM
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In my job answering emergency calls I once posed a similar question to a colleague. His response was that we have to show them that someone still loves them, even if they don’t love themselves.

Posted by: Once was a vegan at November 6, 2005 12:03 PM
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I work in an acute psychiatric setting, and perhaps a third of our clients would be described as similar to Dr. Dalrymple's example. Whatever ills were visited on them in earlier years, much of their behavior remains elective now, and there does not seem to be even an attempt to extricate themselves or minimize the damage they cause others. As the resources of mercy are finite in any society, the group they are most clearly robbing is their fellow patients, many of whom have far less ability to control their thoughts and behavior.

There is an anger among caregivers at those who will not even try, as the truly needy are often sitting right across from them, underserved.

Posted by: Assistant Village Idiot at November 8, 2005 01:19 AM
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