Recent changes to the NHS raise the potential for health care providers to deny treatment based on an individual’s characteristics, such as their weight or whether they smoke. I think this calls for a reminder of the implications of discriminating in this way, and why, I think, we would do best to avoid it.
The NHS is paid for by the public, so we generally accept that it should do what the public wants (unless the public gets it wrong, of course). A growing body of literature exists on public preferences for the distribution of health care, and the ways in which people might like to discriminate; at least one review of the literature has existed since 2005. When it comes to organ transplantation, some people show a preference for the recipient to have not caused their own illness. Elsewhere, polls have found that around 40% of people would give priority to such individuals. Despite this representing a large minority it does not indicate wide public support for discrimination based on this. Dolan et al (2008) reported that people give 8% less weight to individuals whose illness can be partially attributed to their own lifestyle.
So, it is not clear that the public wants the NHS to discriminate in this way. If it were clear it would presumably be included in NICE guidance. However, cynical readers will of course recognise that such policies are driven by financial incentives rather than a desire to act in the public’s interest.
8% said Dolan and co. This suggests that, if an intervention is close to NICE’s threshold QALY value, it may be justifiable for the fat smokers to miss out. Afterall, their health gain is of a reduced value to society. However, the real efficiency question is whether individuals responsible for their own health problem are actually likely to have a smaller health gain from treatment. This is a very real possibility, as fat smokers are more likely to experience complications in treatment and whatnot. More research should explicitly consider the impact of individual characteristics on the cost-effectiveness of treatment. But people’s capacity to benefit from treatment could be influenced by many things. If we are to discriminate based on efficiency arguments then we must also discriminate between people based on race, age, sex, sexuality, occupation, where they live, and who-knows-what else.
For me, none of this matters. Clinicians can make judgements in individual cases, and it may be efficient to do so, but I find it hard to imagine a situation where discriminating against individuals based on arbitrary distinctions would increase efficiency. If you don’t treat the fat smokers they’ll probably get more ill. They’ll probably die young. When the cancer spreads and the myocardial infarctions become frequent, it’ll cost a lot to save their lives – a cost that just might have been avoided.