By DOMINIC GILONIS
Recently, I spoke to someone who works closely with the NHS. What, in his view, was the largest problem facing public health? His answer was that we have managed, through undoubtedly compassionate motivations, to ‘add years to life, but not life to years’ - that while we have managed to extend peoples’ lives, we have not increased their ability to engage in life. The answer encapsulated a striking feature of healthcare in the UK - that we, on the face of it at least, treat all individual lives as absolutely equal in terms of value. This ideal is noble certainly, but unfortunately, when the rubber meets the road, the bare realities of scarcity on the one hand and the unaccounted desire for quality of life on the other have to be considered before we scorn dissenting voices as uncaring or offensive.
The latest such voice has been that of Lord Jonathan Sumption, a former Supreme Court justice and outspoken critic of the government’s lockdown policy since its inception in March 2020. Sumption has argued that, given the young had more Quality-Adjusted Life Years (QALYs) ahead of them, their lives should be considered more valuable in public policy. This was challenged by cancer survivor Deborah James who asked if her life did not have value due to her condition. Sumption replied that it did have value, but was ‘less valuable’ than others. He has been fiercely criticised by public health officials and journalists alike for claiming that lives can be treated as having unequal value. He has since claimed that he misunderstood the question, and thought it was questioning whether his life did not have value because of his age (it is telling that he replied his life was of less value); notably, he has never been quoted as saying that some lives lack value altogether.
We should perhaps be willing to take his explanation in good faith, given he is not a professional politician. The criticisms of his view, however, must be addressed due to their faulty premises. They have rested on the claim that it is immoral to even suggest that human lives have variable values. This is a rather naive criticism to make. Variation in the value of life is an accepted principle in much of politics, ethics, and economics (for example if one considers that the appreciation of human life tends to stop at the borders) but especially within the sphere of public health.
The reason for this is not ideological in any sense, but practical. We do not have infinite resources available with which to treat everyone, nor the technology to ensure that they would have a good life even if we had the funds. Judgements have to be made therefore about whether a treatment or intervention is reasonable. The National Institute for Health and Care Excellence (NICE) judges such treatments based on ‘cost per life year saved’, normally around £20,000-£30,000. This might seem heartless or a bit cold, but we make these valuations intuitively as well - ask yourself if in a classic trolley problem you would rather save a baby or a grown person and it becomes obvious. The practical realities of a world of scarcity force us to make these calculations.
It should be asked here what the alternative is to making these judgements. There are two options: leave them to the market, and let those with the cash to pay have treatments, or fund every treatment that has a non-zero chance of prolonging someones’ life. The former is unacceptable in the UK, where the NHS is sacrosanct. The latter is simply unsustainable; even if all treatments were successful, it is impossible for such a system to be funded for an indefinite period of time.
It could be said that it was insensitive for Sumption to claim this of a cancer survivor, given that such conditions are not the individual’s fault or responsibility. This would be more convincing if it were not for the government making similar calculations implicitly. Mr David Twigg MP highlighted the increasing delays in cancer treatments just two weeks ago, while the loss of screenings from the first lockdown will inevitably lead to greater human suffering. The underlying assumption in the government policy is that COVID poses a greater threat to the public health than cancer. Therefore, resources and attention should be dedicated to the virus instead, which implies that cancer patients have a lower priority (or value) to healthcare providers. Whether this is a good or bad thing is up for discussion, but we cannot ignore the value of judgements inherent in prioritisation, and nor should we necessarily conclude that people make them out of malice.
The attempts to dismiss Sumption as a cold-hearted reptile are at best immature and at worst disingenuous. The man is an extremely accomplished academic and lawyer, which perhaps explains his dispassionate and logical view of things. It is unfair to mischaracterise his argument as being that some people are ‘lesser’ than others; rather, it is that the value of life in political calculations is not necessarily universally the same. Hard decisions about resource allocation and treatment options are made every day by healthcare officials; we can choose to ignore them, and take inconsistent moral stances, or we can choose to listen to people when they highlight practical difficulties. Morality is, at the end of the day, a practical subject.