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Matters of Life and Death

An extract from the book Matters of Life and Death giving a Christian response to the consequences of limited resources in the NHS

It is a commonplace observation that the real costs of healthcare are rising inexorably, year on year, in every developed nation worldwide. It is absolutely clear that no nation can afford all the possible treatments which might be provided for its citizens.

At the same time, the shameful gulf in resources between the developed and less-developed worlds increases. Rationing of scarce health resources is inevitable in every society in the world. But how should resources be allocated in a way which fits with Christian convictions?

In the UK, the traditional solution within the NHS has been that of covert rationing by doctors and managers. In ways which are frequently concealed from the patient and the general public, doctors and managers have restricted the availability of treatment to those whom they believe can most benefit, or to those who seem most worthy of treatment. Traditionally, priority has often been given to those with the greatest medical need who were most likely to benefit from treatment. This has meant that those with serious acute illness and those with most dependants have often been given preference over people with learning disabilities, mental illness, the diseases of old age, or chronic disability. In response to public pressure and a desire by managers to reform the process of allocation, managers and health planners have started to experiment with alternative models which make allocation decisions more open and transparent.

Open and transparent

The problems of resource allocation in modern societies are complex and divisive. They raise unavoidable political issues. I am reminded of the words of the murdered Salvadorian priest Oscar Romero: 'When I give bread to the children, they call me a saint. When I ask why the children have no bread, they call me a communist.' Christian thinking on these matters is under-developed, and there is an urgent need for fresh, innovative and practical solutions. Along with many other clinicians, I am conscious of my own limitations and lack of expertise in this area. All I can offer are some basic principles from within a Christian worldview.

1. The allocation of resources should be open and transparent, rather than covert. Decisions need to be open to public debate and democratic challenge. We need to institute checks and balances which prevent abuse and manipulation by powerful interest groups. The UK spends less on health as a proportion of our national income than the vast majority of other developed countries. Is this because the UK public have decided that health is a lower priority than in other countries? Is it because our need for healthcare is less than that of other countries? No. Although our system of healthcare is almost certainly more economically efficient than that of many other countries, the health budget in the UK at least in part reflects covert rationing by politicians and civil servants. The question of the magnitude of health spending for the country as a whole has rarely been open to public debate and challenge. Over the history of the NHS, the democratic process has failed to provide a genuine debate. Similarly, we spend less on health aid to developing countries as a proportion of our national income compared with many other nations. Is this because the UK public is more selfish and less generous than people from other nations? Again, it seems to be a failure of the democratic process. Here is a challenge for innovative Christian political thinking and action.

Care for the most needy

2. We need to demonstrate a practical concern for the weak and vulnerable in society. We need to defend the modern equivalent of the widows, orphans and aliens of the Old Testament law - the dying, the chronically disabled, the genetically stigmatised, the elderly, the immigrant, the abused child, the chronic psychiatric patient, and the malformed foetus. We need a system of healthcare allocation which does not allow the powerful, those with an influential voice or economic muscle, to silence the needs of the vulnerable. One of the major threats of the new biotechnology industries is the commercial power which distorts health priorities away from unfashionable low-tech caring towards exciting and profitable high-tech interventions. We need structures which will resist the growing power of commercial interests in the healthcare world.

Fairness

3. We should strive for equality and fairness across social, racial and geographical divides. If we are all made as one family, locked together in bonds of mutual responsibility, mutual burdensomeness, then we need to care for one another with equality and fairness. Gross inequalities in health provision are destructive of social welfare and cohesion. Of course the most painful and inescapable inequalities lie in the gulf in health resources between rich and poor nations. It is an inequality which represents a scandalous affront to the dignity of the entire human family. As in the past, Christians should be in the forefront of international efforts to reduce gross inequalities in health resources.

Holistic approach to need

4. We need to resist the reductionist economism which measures the costs and benefits of caring in purely financial terms. As an alternative, we need to develop a holistic approach to health economics which, while sensitive to the financial controls and efficiency which are part of good stewardship, appropriately values the human, social and spiritual aspects of caring relationships.

5. We need to allocate limited resources based on need and effectiveness, irrespective of fault. Although this raises complex issues of personal responsibility, Jesus stressed that Christian compassion should be impartial, bestowed alike on the deserving and the undeserving. We have already noted his words in the Sermon on the Mount: 'I tell you: love your enemies and pray for those who persecute you, that you may be sons of your Father in heaven. He causes his sun to rise on the evil and the good, and sends rain on the righteous and the unrighteous.' (Matthew 5.43-45). We need to find innovative ways of combining the distinctive biblical virtues of justice and mercy.

Realistic expectations

6. Finally, we need to encourage the community as a whole to develop realistic expectations of the benefits that healthcare treatments can bring, and foster responsible recognition of the limits imposed by finite medical knowledge and expertise, limited resources and the fundamental nature of our humanity. Christians can take a lead in opposing the idolatrous tendencies of modern medicine to seek technological solutions to all the problems of the human condition.

These are some of the principles which should guide the development of a Christian response. But I am painfully aware that it is not enough to enunciate theoretical approaches unless they lead to practical action within our community. We urgently need the assistance of those who have the ability and the experience to translate these principles into practical initiatives at a local, national and international level.

Reprinted with the author's permission from 'Old values for a new century', a chapter in Matters of Life and Death, by John Wyatt, published by IVP/CMF (ISBN 0 85111 588 8). £9.99.