The Rules Will Be Enforced

“Use every man after his desert, and who shall scape whipping?” — Hamlet, Act II, Scene 2

In a world of perfect justice, each man would receive his due and nothing else, as Shakespeare’s words suggest. Whether such a world is possible or even desirable is another question.

I suspect that we would all hate it. Justice, after all, is not the only desideratum of human existence, though considerations of justice have a tendency to madden men’s minds and drive all other considerations clean from them. To say that an arrangement is unjust is tantamount to saying that it should be brought to an end—for who would ever defend injustice? Let the heavens fall so long as justice be done.

The question of justice is an important one in medical ethics. How far should a patient be held responsible for his own health, and what should be the consequences of his willful disregard of it? In Britain, a hospital has suggested that patients who have a body-mass index of over 30 or who smoke cigarettes should have their operations (if they are routine or non-emergency in nature) postponed by six to 12 months, unless they lose weight or give up smoking. This proposal was made on the grounds that fat patients or those who smoke have worse post-operative outcomes than others, and it is ethically desirable or even mandatory that, where medical resources are limited (as they always are), the maximum benefit from medicals endeavors should be obtained.

Strictly speaking, the proposal is not entirely logical since, at the end of the six months or a year, the outcomes for the recalcitrantly overweight or smoking patients will still be worse than the outcomes for other patients who will, presumably, still exist and be in need of their operations. In other words, to make the argument for postponing completely sound, those who were overweight or were smokers should be denied operations until no one else was in need of them—which would be never.

The proposal also implies that “the recalcitrants,” if we can call them that, have voluntary control over their own condition: that they could lose weight or give up smoking if they really wanted to, in a way that they couldn’t stop having Crohn’s disease or ulcerative colitis if they wanted to. This seems to me, in the abstract, to be correct, but the hospital that wants to postpone routine operations on the recalcitrants also says that it will not postpone or desist from bariatric surgery—that is to say, surgery to reduce the weight of the morbidly obese. On the one hand, then, morbid obesity is to be regarded as a consequence of weakness of will; on the other, it is treated as if it were a bona fide disease.

It is difficult to be entirely consistent, at least while also being humane. If, on the one hand, you say that everyone should be forced to bear the consequences of his own weaknesses and sins, you risk a moral rigor that you are most unlikely to want applied to your own case. But if, on the other hand, you deny that other people are responsible for their own fate, you risk dehumanizing them, and giving yourself carte blanche, at least in theory, to interfere in their lives—to direct, bully, or force them to do what you think is in their interest to do.

The problem of priorities and the degree to which treatment should take the conduct of patients into account is not unique to systems such as the British National Health Service, which supposedly is funded according to ability to pay (taxation) and provides service according to need: the old Marxist “From each according to his ability, to each according to his need” applied to health care. Systems, on the other hand, that rely on individualized insurance payments decide how much an insured person should pay in premiums by taking into account not only the person’s conduct, but the person’s previous illnesses, over which he had no voluntary control.

The problem with the nationalized system’s incontinent sharing of risk is that it deprives people of one possible motive for behaving responsibly with regard to their own health. They believe, not without reason, that someone will always pick up the pieces for them at no cost to themselves. And irresponsibility thrives where there is no penalty for it. The problem with individualized insurance, though, is that it may place intolerable or unsustainable burdens on people through no fault of their own.

Incontinent sharing of risk is unjust; too little sharing of risk is inhumane. Since both justice and humanity are desirable qualities, but not always compatible, now one, now the other, will be the more important; but the tension between them will remain.

Perhaps, then, the proposal of the hospital in Britain is not as absurd as it first appeared. It is not consistent in a philosophical sense, true enough, but consistency in the face of inconsistent desiderata would be no virtue. It does not altogether deny the “recalcitrants” treatment, which would be inhumane; neither does it deny that (in conditions of shortage) these individuals are somewhat less deserving of immediate relief than others.

That ethical decisions sometimes cannot be made that are indisputably correct, that entail no injustice or no inhumanity, is difficult for rationalists and utilitarians to accept. They want every division to be without remainder, as it were. They want a formula that will decide every question beyond reasonable doubt. They want a universal measure of suffering, so that the precise worth (in units of suffering averted) of every medical procedure can be known and compared. Health economists tend to take this type of measurement very seriously; if they come to the conclusion that knee replacements avert less suffering than removals of cataracts, they advocate that more of the latter be done at the expense of the former.

There is a kind of cognitive hubris at play, according to which information alone will resolve all our dilemmas; and if our dilemmas have not been answered, it is only because we do not have enough information yet. The hope or expectation of a dilemma-free world is naïve, where it is not power-hungry.

As for the doctor, he cannot be so limitlessly compassionate as to deny patients’ responsibility where it exists, nor should he deny his patients his compassion by blaming them even when they are to blame.