The rationing debate: Maximising the health of the whole community. The case against: what the principal objective of the NHS should really beBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7081.669 (Published 01 March 1997) Cite this as: BMJ 1997;314:669
- John Harris, professor of bioethics and applied philosophya
- a Institute of Medicine, Law, and Bioethics, Universities of Manchester and Liverpool, Centre for Social Ethics and Policy, Manchester M13 9PL
Patients rationally want three things from health care. They want the treatment that will give them maximum life expectancy coupled with the best quality of that life, and above all they want the best possible opportunity of getting the combination of quantity and quality of life available to them given their personal health status. I believe that each citizen has an equal claim on the protection of the community as expressed by its public healthcare system, and this means that each is entitled to an equal chance of having his or her, necessarily individual, health needs respected by any publicly funded healthcare system.
Means and ends
It is common ground I suppose that we have to think about the ethics both of means and of ends. Even if it were to be accepted that the healthcare system ought principally to aim at maximising aggregate health gain, it does not follow that the most effective ways of achieving this are legitimate. If all seriously ill people were to be allowed to die this might dramatically improve the aggregate health of the community at large. I hope such a policy would not seem ethically defensible. Yet this is precisely what measures which use quality adjusted life years, or similar mechanisms, do: they systematically accord preference to those who have better health prospects, and, by selecting against those with worse prospects, tend to improve the aggregate health status of the whole community at the expense of the life chances of those with poorer prognosis.
We should notice that to make aggregate improvements a principal objective, even if not the only objective, is to imply the subordination of the health needs of individuals to something very abstract, and in some circumstances something very trivial indeed–namely, the improved health status of the whole community. For this could imply …