Tuesday, 24 March 2009

The NHS can't go on

This is a guest post by Julian Mann

Heresy Corner has emerged as a Cave of Adullam for various cultural outlaws including this Evangelical Christian. The Heresiarch's houseguests are diverse in their spiritual and moral perspectives. The heretical question developing in the mind of Cranmer’s Curate is this: for how much longer can the National Health Service operate without making moral judgements in the prioritisation of treatment?

There is still, thank the Lord, fantastic medical expertise and professionalism in the NHS and amazing cures are achieved for conditions that were absolutely fatal within living memory. That should be celebrated. But it is also clear that administratively the NHS is creaking under the enormous strain of the expectation placed upon it to act as the all-treating, all-embracing, non-discriminating, rainbow-shaped deity of post-Christian Britain.

Cranmer’s Curate recently heard an eye-witness account of the situation in a hospital where he frequently visits his parishioners. Some wards have had to be closed because of a break-out of infection and so an eclectic temporary ward has had to be set up which includes patients recovering from serious operations. It apparently bears an uncanny resemblance to an airport lounge in a banana republic and a dangerous one at that. Recently, the police had to be called in to restrain a drug-abusing patient armed with a knife that he had taken from the kitchen area and pepper-spray had to be used.

Like it or not, the NHS was originally the product of a society saturated with the Christian values of Victorian Britain, which was itself to a significant extent the spiritual and moral offspring of the Evangelical revival of the 18th century. The overwhelming majority of those the NHS began to treat free at point of need in the Britain of the late 1940s were ill because of no direct fault of their own. Many of those it initially treated had suffered injuries whilst serving their country in two world wars, including the gallant grandfather of Cranmer's Curate.

The NHS was not designed for the society that has emerged as a result of the social revolution of the 1960s with now high levels of drug abuse, obesity, and alcohol-fuelled violence as well as the overwhelming sense of entitlement to other forms of treatment for conditions that the stoics of old Britain were simply prepared to live with.

No mainstream politician dare ask the uncomfortable question about moral prioritisation. After all, ‘judgementalism’ is the ultimate sin in postmodern Britain. This sin may be avoidable in the celebrity fantasy world of the have-it-all, me-society but it is difficult to see how the exercise of moral discrimination can be avoided in the real world.


Wasp_Box said...

Precisely which moral judgements would you expect to apply? You smoke so take your heart attack elsewhere. You didn't wear a condom, live with your HIV. You did wear a condom, live with your HIV (Catholic version).

There are quite a few doctors who operate a one strike system now e.g. we will treat your coronary insufficiency but if you don't stop smoking we won't continue to treat. This seems not unreasonable but going any further fills me with dread.

Many of the problems in the NHS relate to foolish administration and idiotic target setting. There is also the dreadful waste of money on hospital chaplains and facilities for the religiously deluded. We could save some money by getting rid of them but, perhaps, you would see that as morally wrong.

Incidentally, I don't think the Lord has much to do with medical expertise; I think you'll find that it's mainly down to good scientific training.

valdemar squelch said...

So, as a Christian, you think some people are more deserving of compassion than others? 'What Would Jesus Do?' 'Yeah, verily, I say unto thee, taser the chavs.'

Also 'the social revolution of the 1960s' was as nothing compared to the Thatcherite revolution of the 1980s, which is where the drug abuse, obesity, crime and so on originated.

I'm surprised to see such a shoddy Daily Mail canard repeated here. In the Sixties having a job was normal and the UK had near full employment. The fantasy, Paul Dacre Sixties was all about drugs and communes. In reality, it was a rather conservative decade.

The problems you describe, while very real, are down to a right-wing government that was headed by a churchgoing Christian with a line in being holier than everyone.

For whatever reasons, Thatcher destroyed or dislocated much of the old, white working classes and so created a parasitic and destructive underclass in which having a regular job is exceptional (and therefore something only exception individuals, always a minority in any social group, will achieve).

Cranmer's Curate said...

Thank you sir for hospitality.

Manifestly the NHS is not Jesus. It's being expected to be God Incarnate but quite understandably is feeling the strain.

Those are absolutely the right questions re moral judgements in healtcare going forward: which moral code will be applied and who will make the judgements?

That the current situation is unsustainable is surely not open to question.

indigomyth said...

//Like it or not, the NHS was originally the product of a society saturated with the Christian values of Victorian Britain, which was itself to a significant extent the spiritual and moral offspring of the Evangelical revival of the 18th century.//

Though not strictly speaking "on topic", would this be the society that had this
or this
or was it perhaps this
or this?

To be fair though it did also see this
So perhaps, at best, we can say a mixed success for a society "saturated with Christian values"?

valdemar squelch said...

indigomyth, you are too generous. The NHS was the product of socialist thinking, for good or ill. It was one logical outcome of a war fought and won by a citizen army and home front workers who decisively ousted Churchill and voted in a socialist government - people who didn't want to hear empty guff about a 'land fit for heroes' and then be sent back to the dole and the slums. What Christianity had to do with any of this is beyond me. Religion may have been important to some individuals, but the majority of people during and immediately after WW2 were secular in outlook.

Edwin Moore said...

Excellent piece, many thanks Julian.

Having spent most of last week in Glasgow's Western Infirmary with a sudden onset of DVT and pulmonary embolism, and having seen first hand the wreckage that drifts through the wards, all of this is very much on my mind.

Sitting on a wheelchair in a holding pen, I saw a young troubled woman be escorted back and forth to the toilet by two nurses and two cops. From Tuesday to Friday I saw a lot of suffering, a fair proportion of it self-inflicted. It's all much worse after the football on Saturday.

Of the many conversations I had with staff, one in particular sticks in the mind. I asked a porter how he saw the future, and he said the drug scene was going to change dramatically in a decade or so. For now the grannies are holding the fort, caring for the grandchildren while the generation in between gets wasted. 10-15 years from now, those grannies will be gone, and the wasted mums of today will be the grannies, but grannies incapable of holding anything.

He said when that happens, the NHS in Scotland will either break down or would be forced to prioritise in ways now unimaginable. The one thing, in fact, everyone I spoke to there seemed to agree on was that the future is going to be very bleak.

Hugo Williams recently pointed (in the TLS) to one unexpected good thing about the NHS, having seen his sister die in private care - the NHS lets you die quicker, it's less costly.

FrankFisher said...

The key issue isn't morality - it's money. Like the welfare state the NHS is unaffordable. Will either existing in their current form in 50 years? Inconceivable. So when do we grasp the nettle and slash 'em down?

apashiol said...

Will we discriminate between illnesses based upon antiquated notions of free-will that genetics, psychology and neurology continue to show up as fundamentally flawed?

Is someone's predilection for red meat which gives a higher risk for cancer morally more reprehensible than someone's alcohol consumption that can lead to cirrhosis?

What about a government that collects tax revenue on alcohol and tobacco? Is it right to turn around and punish those who then indulge by denying them healthcare for the illnesses that can come from using those products?

I am a vegetarian who doesn't smoke and has an occasional alcoholic drink, so statistically I run few risks that would mean needing medical attention.
Yet I would say that what passes for moral discrimination is more often scapegoating those with the least means to make healthy choices.

It has often been pointed out that the health of the British was best just after WWII when rationing meant people couldn't access the things that cause most health problems.
It would be hypocrisy if, on the one hand, we sing the praises of a free market that encourages and exploits the worst side of human nature, and on the other, we punish them for being human.

Any judgement made on what is damaging to society should be at least based on the best scientific evidence, not on some subjective moral judgement based on personal distaste.

John said...

Excellent thought provoking article. The closed-mindedness of the atheist or secularists above is also thought provoking.

valdemar squelch said...

apashiol, excellent points. I would not want to live in a country where yet another committee of unelected twerps decided on my moral worthiness and its relationship to my place an NHS queue. As a boy I had congenital cataracts, which required extensive surgery to save my sight. NOw, forty years on, the NHS is again required to treat complications (much delayed) that mean I am losing the sight in one eye.

Now, how happy would I be if, instead of a consultant making a decision on treatment, a gaggle of smug, priggish evangelical Christians were to quiz me on my morals? Just as we all have the same number of votes, so we all have the same access to health care or the same rights before a judge and jury.

indigomyth said...

John said
//Excellent thought provoking article. The closed-mindedness of the atheist or secularists above is also thought provoking.//

Which element in particular did you think was "close-minded"? I merely highlighted some of the elements of Victorian society that Cramners Curate elected to not mention, presumably because they rather detracted from his idealistic construction of a Victorian society basking in the radiance of Christianity. Perhaps it is you and he that are close-minded?

Now, I do actually happen to agree with him to a certain extent, with regard to prioritising the NHS system, and also that the problems of deciding who gets treated and in what order are significant and uncomfortable ones.

Would you care to retract your accusation of "close-mindedness", or at least have the decency, not to say intellectual rigour, to demonstrate where you believe that I have been close-minded.

Cranmer's Curate said...

Thank you Mr Moore for your kind remarks. I'm sorry to hear about the awful time you had in hospital, which you seem to have endured with better grace than I would.

Victorian society was very far from perfect, but it was re-moralising. Christian Parliamentarians such as Shaftesbury & Gladstone were laying the legislative foundations for the welfare state. This was supported and indeed driven by a phenomenal amount of individual philanthropy, including the astonishing achievements of Florence Nightingale.

Edwin Moore said...

The context in which we discuss the NHS is changing in ways comparable to the way we used to discuss private and public education. I know people with children in private schools who would not, could not have conceived of doing so 15 years ago - all has changed, changed utterly.

Our medics are making life-and-death decisions already on the basis of who is worthy, and it is taking a fearful strain on them. If you're an A&E guy on a long. long shift, and at 3am you have to give your attention to both a sick child and to a drunken fool with a blade wound shouting abuse at you, you concentrate on the sick child - of course you do.

Incidentally, apashio, I too am a (30-decade) veggie, but what does counts in your favour when you enter the NHS process as a patient is being a regular blood or platelet donor (I'm out for 6 months now alas!).

Anyone remember the film Jesus of Montreal and the wonderful charity public-service hospital at the end? It was only the 70s, yet now it looks like some strange SF/Chestertonian parable of charitable care, and utterly remote from th health servive we have.

apashiol said...

Victorian society was very far from perfect, but it was re-moralising.

Victorian society did better the lot of the poor by improving housing, starting trade unions and regulating factories and workplaces. Then you had public education and improved health care. In the sense that poverty is demoralising, any efforts to ameliorate the class divide and lift people out of poverty could be interpreted as re-moralising. Not in the sense of some spiritual awakening to Christian values.

Alcoholism was rife then, along with prostitution. The streets were full of abandoned children. You had the slums which were as bad as any of the sink estates in Britain today.
John Stuart Mills wrote 'The Subjection of Women" where he described how women were treated like slaves.
We certainly have problems today but it's still a sight better than those times.
If better health care and greater equality contributed to the improvement of society I don't see how recreating an undeserving class will somehow further it.

apashiol said...

I knew a vegetarian diet was good for the health but 30 decades?
Wow! ;)

Edwin Moore said...

ooops sorry apashiol! Three decades only of course though sometimes it feels like three hundred!

God the older I get the more I love Hardy's 'An Ancient to Ancients'.

The Heresiarch said...

I've enjoyed this discussion of an important topic, and I'm pleased CC saw fit to write so provocatively.

Before I dive in, firstly to Edwin, I'm sorry to hear about your recent troubles. Hope you make a full recovery, and quickly.

It is, of course, the case that some hard choices have to be made. But the present predicament doesn't result from lack of resources. The present government has chosen to lavish unprecedented sums of money on the NHS, tripling its budget, but no-one would claim that the service is three times better as a result. On the contrary, in some aspects (cleanliness, for example) it has deteriorated. Reasons for this include the target culture, which leads to perverse incentives and bad prioritising; over-payment of staff, especially doctors; too much money being squandered on high-profile and ruinously expensive building projects; too many monitors, administrators and bureaucratic panjandrums, all of whom have to be paid - every penny they earn is a penny that is NOT spent on treating patients. These problems have the common theme of centralisation. Not making moral choices seems to me the least of it - and as Edwin points out many such choices are, and have to be, made already.

On the point about the NHS's Christian roots, I think Julian has a point. Of course, Valdemar is right that the system of the NHS is the result of socialist planning, and the idea of a universal system funded by general taxation is a socialist one. But it was still the product "of a society saturated with Christian values"; those hospitals didn't come from nowhere, and there was already something approaching universal healthcare before 1945. One of Labour's rhetorical tricks has been to convince people that before the NHS only rich people had access to doctors or hospitals. Of course, there used to be far more disease and general ill-health and lower life-expectancy. But the same is true of all advanced societies, including the US.

The obesity "epidemic", "time bomb" or whatever has been much exaggerated: that isn't the true cause of the crisis, which is largely attributable to an ageing population. It's actually a lot easier for the NHS if fat binge-drinkers die quickly from heart attacks than if they linger into old age and need longer-term treatment. A more abstemious population wouldn't cost the health service less (that's one of the great fallacies of the age) it would just cost the NHS differently.

The judgementalism towards the fat or the alcohol-dependent is certainly there, but it's based on an entirely secular morality that stresses healthiness as equivalent to virtue.

Apashiol is right, to an extent, that some people's bad choices may be genetically determined (or, alternatively, the answers may be sought in their background). But if you took that argument to its logical conclusion the criminal law would quickly become a subset of medicine, and it would become hard to resist the arguments of eugenicists. Free will may be an illusion, but it's an illusion necessary in a functioning society.

apashiol said...

While I am a determinist I do see room for a limited self-determination.

I baulk at suggestions of moral discrimination due to the mounting evidence of how the idea of moral virtue has an embodied element. It is perceived as akin to physical cleanliness.
Inducing disgust or feelings of dirtiness can cause people to form more severe moral judgements.
The opposite has been shown too, where the simple act of having people wash their hands can influence them to judge others more favourably.
The knowledge that we can be psychologically primed like this seems to warrant greater care to engage our reason.

Matt said...

One thing's for sure, If a judgment were to be made on the obese or the drug-dependent as unworthy for treatment, exactly the same judgment would logically apply to anyone injured as a result of sporting activity engaged in purely for pleasure, and in fact, anything done for that purpose.

Pleasurable feelings are mostly the result of chemicals being released in the brain. Whether the release of such chemicals is induced by taking drugs (I include alcohol of course), stuffing your face, snowboarding down a mountain, playing rugby, taking a country drive, or anything else, is irrelevant.

WeepingCross said...

Julian, I share some of the doubts expressed about your historical analysis of the NHS, but I think your basic point is sound, that it's struggling to do things now which it wasn't designed to do.

But if you're moving on from that to ask, if prioritising there must be, which ideology governs the prioritising, I don't see that it can be in any way a Christian one. Either Christians will not agree about the basis of 'desert', in which case the very term 'Christian' needs more unpacking; or they will, and I feel should, deny the validity of dividing human beings into those who deserve help and those who don't. God doesn't, so nor can we. This underlines again the impossibility of using 'Christian' values as a legislative blueprint -if we're serious about them, which of course Christians may not be really.

Matt, I think your last point is excessively reductive. Pleasurable activities do differ; some inevitably involve harm (meaning impaired mental or physical function as normally defined) while others do not; some are rule-bound, or capable of causing pleasure to others as well as the individual doing them, while others aren't. The choice of pleasure is not just arbitrary: it seems implausible to me that an individual might get up in the morning and be as likely either to take up injecting heroin or to join the rugby team. There is a logical basis here for discrimination, should one decide one wanted to.

valdemar squelch said...

As I happens, I'm in need of the NHS at the moment. Shortly after I was born I was diagnosed with congenital cataracts, which required extensive, Sixties-style surgery. Now, after four decades, complications have set in and I'm in danger of losing my sight again. I dare say any NHS treatment for men will cost - eventually - cost thousands of pounds.

Arguably I am morally pure, in that I did nothing to bring blindness upon myself - apart the thing every lad's mother warns him about. But the truth is, I would rather a lottery (a real, non-rigged one) were used to allocate resources to patients that some prodnose ethics committee.

Perhaps the problem here, though, is that some of us are taking about morals and laws as if they were the same thing. A drunk who tries to stab a nurse is a criminal in any society - even Scotland. But George Best and Gazza are examples of illness brought about by definitely stupid, and arguably immoral antics. Drug addicts get a far worse press than boozers, but the difference seems slight to me (morally, I mean). I

ndeed, go back to the supposedly Swinging Sixties, and what do we find? The criminalisation of drug abuse that had previously been an entirely medical issue. Moral panic, bad law, terrible social legacy.

Matt said...

"Matt, I think your last point is excessively reductive"

I'd argue that viewpoint emerges for no other reason than that society tells us so. I see no logical or moral difference.

"Pleasurable activities do differ; some inevitably involve harm (meaning impaired mental or physical function as normally defined)"

Inevitably? I doubt many of the small percentage of people who end up harming themselves by indulging in pleasures such as drugs actually start taking them with harming themselves in mind, just as those engaging in dangerous sports don't either. Neither inevitably cause harm, the difference is only in the probability of harm, and all popular drugs bar heroin, that probability is pretty low.

or are you not talking about permanent harm as I'm assuming, but defining inebriation itself as harm?!?

"some are rule-bound"

I'm not sure what relevance that has.

"or capable of causing pleasure to others as well as the individual doing them, while others aren't."

Ditto. I don't see how altruism is a required motive for pleasure to avoid immorality. I'd argue that it's not harming others certainly is, but that's all.

Anyway, most of the sports I'm talking about +are+ individual, For example, driving fast cars around a track, snowboarding etc.

"There is a logical basis here for discrimination, should one decide one wanted to."

Because of the permanent-harm probabilities involved (and these alone - certainly nothing moral) I'll concede you could discriminate between the extremes - drugs that are almost inevitably harmful like heroin, and sports that are rarely harmful, but you'll need to reveal some hidden logical difference between taking ecstasy every weekend or choosing abseiling instead, for me to retract my original point, which as that in essence these things are no different to each other. It's only about risk percentage.

indigomyth said...

The Heresiarch said
//The judgementalism towards the fat or the alcohol-dependent is certainly there, but it's based on an entirely secular morality that stresses healthiness as equivalent to virtue.//

Is it though? I would agree that certain religious groups do offer and have offered help to the sick and unhealthy, I think particularly of priests and monks of leper colonies, however, with regard to "self-inflicted" morbidities, I do think religious ideas and sensibilities are largely callous to the needs of the patients. The fact that greed is a sin, and temperance a virtue, gives some idea of the outlook of certainly the Catholic church on ailments listed above. The old adage "cleanliness is next to Godliness" could literally be applied in certain cases of theology. Such "failings" as being fat or alcohol-dependent are criticised heavily by many religious institutions.

McDuff said...

Does it really still count as "provocative" to repeat the same tired old moralistic canards about the "deserving" poor, how the decline of the country is all the fault of those damned hippies, things were so much better in the old days and, incidentally, the solution to everything is more Christianity? Really? From here what few sections of the post passed for thought at all committed a graver sin than being fallacious, incorrect or so tiresomely based on anecdote as to be virtually ficticious: this line of argument is boring.

We've heard it all before. For pity's sake, Hogarth was publishing waggy-fingered prints chastising the immoral poor way back in the 18th Century, and he was by no means the first to come up with the argument that there's an element of society poor by its own laziness and therefore undeserving of charity. Amusingly given that the bible specifically says that charity is the greatest of all virtues it remains a popular theme among those who call themselves Christian.

It's oversimplified tosh and gubbins, written to salve the consciences of the thoughtless middle class who can't bear the idea that their relative security and happiness might well be the result of accident rather than moral virtue. It always has been and it always will be. Ancient ideas trotted out for their umpteenth outing like a rheumy-eyed blackpool donkey aren't provocative at all, and I wish that people would stop granting such moral illiteracy the undeserved veneer of legitimacy by declaring that such piffle is anything new or exciting or the fruits of a fresh mind speaking truth to power.

I must say, this kind of writing is far below the usual standard of thought I'd expect to find on the blog. Can we have a higher quality of guest blogger in future, rather than someone more at home writing letters to the Daily Mail?

valdemar squelch said...

Yeah, what he said. I was surprised to find such a post here - surprised and dismayed. If HC is about countering complacency, received opinion and incoherent thought, giving houseroom to religious fundamentalism is a clanger. Major clanger, in fact.

McDuff said...

I wouldn't even credit this nonsense as being "fundamentalism". At least fundamentalism has some personality and oomph behind it. I'd prefer a decent fundamentalist rant to this petty drivel.

Cranmer's Curate said...

It is actually great credit to the Heresiarch that he is willing to give houseroom to a worldview he seriously disagrees with. That shows he is sincere in his commitment to free speech.

The very real and practical issue those of us who have participated in this discussion are grappling with is the question of moral choices in healthcare and what moral framework is applied. Also, the question of the changing nature of the society that offers a national health service funded by the taxpayer is surely pressingly relevant to the current problems the NHS faces.

sanbikinoraion said...

Cranmer's Curate - in which case, I hope to see an equally disgusting post by Nick Griffin proclaiming that Pakis are scum any day now.

Or not.

indigomyth said...

I have always thought that the EU should take a census of all those who do not wish to participate in embryonic stem cell research, and then, if any life saving medicines are developed as a result of that research, deny those same people treatment. If they want to prevent society from discovering life saving and health restoring treatments, on the basis of their faith, then I would say that if such developments went ahead, it would be poetic justice for those objectors to die when a cure they opposed the development of is available. It would, at the very least, indicate the depth of their faith.

What think you, Cranmer's Curate? Good idea to forcibly prevent religious fundamentalists from receiving treatments developed as a result of embryonic stem cell research, or not? Would you have the faith to eschew such treatment, even if death was certain and agonising, and the treatment free, painless and easy?

Cranmer's Curate said...

The guest-post was not as far as I can see abusive of any group in society. The only group that seems to be getting the abuse here is Evangelical Christians.

Re the point about stem cell research, if there is to be moral priorisation of healthcare (unavoidable eventually I would submit) it should be on the basis of individuals' behaviour not their beliefs.

Over and out from me on this. Thank you again to the Heresiarch for his hospitality and all best wishes for a good recovery to Edwin and Valdemar.

indigomyth said...

//The guest-post was not as far as I can see abusive of any group in society. The only group that seems to be getting the abuse here is Evangelical Christians.//

I am a little perplexed by this accusation. I have not been abusive. I have not called you names or insulted you in anyway. In what regard do you think I have abused you?

My question to you was about the morality of opposing research, but being quite happy to benefit from treatments resulting from that research. Is it not Evangelical Christians that are abusing the rest of society by opposing stem cell research, which has the possibility of yielding life saving treatments, all because of their faith, and belief in the "rights of the unborn". In a very real way, they are asking those that do not share their beliefs to die for them. "You are not allowed this treatment, which would save your life, because it offends my religious sensibilities" seems a rather poor argument as to how to run a health service.

I am uncertain about allocating healthcare based on behaviour rather than beliefs. Consider a neo-Nazi, racist, anti-Semite, white Supremacist is taken ill with appendicitis. Now consider that at the same time, a charity fund-raising volunteer, a racial equalist, a campaigner for human rights, is badly injured in a car crash of their own causing due to sloppy driving. In this case, it is the latter that is responsible for their predicament, not the former. Yet I would hesitate before saying the former deserves treatment more than the latter. Yet this IS because of the formers beliefs, not for any behaviour that caused their ailment.

Any thoughts, anyone?

Cranmer's Curate said...

I was not accusing you of being abusing Evangelicals sir. You haven't. The point I was trying to address was that the post just before yours made an unwarranted comparison between the guest-post and racial abuse from the leader of the BNP.

I would be interested to read what others say in response to the interesting question you raise.


Julian Mann

indigomyth said...

Julian Mann

I am curious. Your post indicates that you feel like a "cultural outcast"; in what way do you feel that?

I am aware of quite substantial blogs and resources on the net for Evangelical Christians. To be honest, it is not many EC's that would feel comfortable writing on an ardent atheist's blog. Do you find yourself at odds with the EC communities on the web?

In short, I am curious as to why you read The Heresiarch? What is it about it that you enjoy? Or when you refer to a "Cultural outcast" are you referring to the apparently dominant English culture of generalised irreligion and liberalism? In which case, I am still confused as to how The Heresiarch is a break from those things (particularly the former).