Hugh McLachlan: Not every care cost can be met

An ageing population means tough choices must be made on care. Picture: Getty

Professor Ian Frazer has forcefully and perceptively raised important questions about the provision and allocation of NHS health care in Scotland. (‘Healthcare for elderly may become unaffordable – doctor’ The Scotsman, 17 June) The response of the Scottish Government is unhelpful.

Professor Frazer notes that health care for the aged is particularly expensive. As life expectancy increases and the proportion of older people in the population increases, the problem this creates for public finance will intensify. He suggests that we should consider discrimination on the basis of age in the allocation of NHS health care.

He argues that: “We have to be realistic and say if you spend the resources on treating an 85-year-old with pneumonia, then you won’t be able to treat a 35-year-old who’s had a car crash. It is as simple as that.”

He continues: “The 35-year-old is likely to recover and have a normal lifespan afterwards. The 85-year-old is much less likely to recover.”

A spokesman for the Scottish Government said: “If people in Scotland need treatment, including palliative or end-of-life care from our NHS, they will get it – regardless of age or condition.” This is ambiguous. It might mean that regardless of our age and condition, we will always get from the NHS whatever limitless medical treatment we need.

It might mean that whatever limited treatment the NHS has available to distribute, it will be distributed without regard to the age or condition of those who request or require it.

On either interpretation, the claims are contestable.

What counts as treatment and what counts as need are contentious matters. Furthermore, it is arguable that age and condition should count with regard to the distribution of health care.

Is, say, abortion a form of medical treatment or, rather, a medical solution to a non-medical problem? Whether or not they are forms of medical treatment, should the NHS provide them? Such sorts of decisions are political ones even when they are not highly contentious. Should, for instance, Viagra be available on the NHS to all who might derive a medical benefit from it?

Sometimes people need medical treatment the state is not able to provide. For instance, in order to survive, someone might need to have, say, a heart transplant. It might turn out that no organ is available.

If we tried to provide on the NHS all that might reasonably be thought of as appropriate medical treatment, it is likely that we would be unable to pay for services such as pensions or free primary, secondary and higher education without raising significantly more money in taxation.

Whether or not we should make such a political decision is a matter of contention and debate. There is always an opportunity cost with particular instances of public expenditure. The money could have been spent on something else. It could have been left in the hands of the taxpayer.

In relation to all publicly provided goods and services, the following sorts of questions are relevant. What should be provided? Why should they be provided? How should they be distributed? Who will benefit from their provision? Who will bear the burden of paying for them?

Politicians like to give the impression they are invariably doing citizens a favour when they promise to introduce a right to receive something or other from the state, free at the point of consumption.

However, if they were more honest they would make it clear that the right to receive the goods and services can be sustained only by the enforcement of a corresponding duty to finance it. Some or other citizens must pay in order that some or other citizens receive. Citizens in general or in particular might prefer the absence of both the right and the duty to their co-existence.

Greg McCracken, policy officer at Age Scotland, said: “… an individual’s life should be valued irrespective of whether they are young or old and we should not seek to prioritise care towards one deserving group at the expense of another, equally deserving, group.”

This is true. Individual citizens should be treated impartially by the agents and agencies of the state. However, it does not follow that we should not make decisions about the allocation of health care. Implicitly or explicitly, we cannot avoid doing so.

Furthermore, in some contexts and circumstances, it does seem appropriate and justifiable to discriminate on the basis of age. For instance, as a matter of political choice, we do not give a state pension to all citizens but only to those who reach a particular age. Similarly, only people of a particular age can have sex or get married.

As a matter of political choice, we might decide to discriminate directly or indirectly on the basis of age in the allocation of state-provided health care. It is not clear cut that this would be, as a matter of principle, unequivocally wrong.

For instance, suppose two people require a life-saving organ transplant when only one organ is available. Suppose one of them is 20 and the other 75.

To whom should the organ be given? We might treat them both equally by giving neither of them their required operation. However, not many people are likely to consider that to be a satisfactory decision.

Would it be wrong to give it, on the basis of age, to the younger person? Perhaps it would but the matter deserves serious public discussion.

Rather than discriminate on the basis of age, I suggest that we should be more ready to accept that some treatments are so expensive that no one should be given them on the NHS no matter how much some people might need them. This includes the prescription of some drugs.

This might sometimes involve the withdrawal of some forms of treatment previously available as the demand for them escalates and not merely the failure to introduce some expensive new forms.

In addition, we should, perhaps, be prepared to discontinue some sorts of treatment that are not particularly expensive for individual patients but very costly in total because of the growing overall demand for them.

Statecraft is not typically about the manipulation of levers of power, regardless of the stale rhetoric of politicians. Rather, it is about formulating and implementing strategies. However, strategies often have unwanted and unexpected consequences. This is partly because other political jurisdictions often develop and implement strategies in reaction to those of their competitors, rivals and neighbours.

If older citizens are better treated in Scotland than they are elsewhere, this is likely to mean that younger citizens will be treated better elsewhere than they are in Scotland.

Those Scots who are young, healthy and have gumption might well be attracted by other countries. They are likely to be attractive to other countries, which will also face the problems associated with a large proportion of older people.

If young Scots leave, young Scots who remain will bear a heavier burden. And the problem may be exacerbated if older Scots who live elsewhere were tempted to return.

• Hugh McLachlan is professor of applied philosophy in the Glasgow School for Business and Society at Glasgow Caledonian University