Eithne Donnellan, Health Correspondent, reports on the recent public debate on equal access to healthcare in TCD
SHOULD GEORGE Best have been given a liver transplant when he had no intention of giving up drinking?
Should someone like Irish scrum half Peter Stringer, if injured after coming off worse from an encounter with a 23 stone rugby opponent, be entitled to the same equal access to healthcare as someone who injured themselves without deliberately putting themselves in any danger? And what about a woman wanting a third bypass so she could go on eating cream cakes. Should she get it?
These were among a host of thought-provoking questions posed during a public debate at the TCD Science Gallery in Dublin last week where the issue of whether all patients should be entitled to equal access to healthcare whatever their lifestyle choice, was up for discussion. Two economists argued they shouldn’t be while a doctor and a politician contended that equal access to healthcare was a fundamental right for all, regardless of what kind of lifestyle they led.
Prof Donal O’Shea, a consultant endocrinologist at Dublin’s St Vincent’s and Loughlinstown Hospitals and an expert in the treatment of obesity, said he considered the motion a very serious and potentially dangerous one. He demonstrated why, giving examples of three patients who recently attended his clinic.
The first was a 24-year-old woman. She’d had a brain tumour some years earlier and after it was removed went on steroids. They caused her to put on weight. And the part of her brain the tumour was in affected appetite and she is constantly hungry. She is now 24 stone.
The second was a 23-year-old man whose mother put off having him for a number of years for career reasons. He was born with Down’s syndrome and hadn’t been able to stick to a diet. He is now 29 stone.
The third patient was a woman aged 44 years, weighing 24 stone. Her mother died when she was a child and her mechanism of coping was through food. She piled on weight and was now looking for help.
Was there any way you could judge which of those patients should, or should not, get treatment, he asked a packed auditorium. His point essentially being that people weren’t necessarily themselves to blame for adopting unhealthy lifestyles or eating habits and why, therefore, should they be denied equal access to healthcare?
Furthermore, he said: “If we are going to judge based on lifestyle choices then we are going to have to be able to log lifestyle choices, produce evidence of lifestyle choices and we would have to have a society that would favour the healthy lifestyle.”
He went on to stress that if patients were entitled to equal access to healthcare it didn’t necessarily mean they all got the same treatment. He suggested giving a liver transplant to an alcoholic like George Best was just “bad medicine”. Access to healthcare for an alcoholic with liver disease should, he suggested, involve treating the alcoholism first.
Prof Charles Normand, a health economist and Edward Kennedy Professor of Health Policy and Management at TCD, argued that sometimes lifestyle choices meant it was less likely people would benefit from certain procedures – like the late George Best when he got a liver transplant but continued drinking. He also maintained those who continued smoking were much less likely to enjoy the same benefits from heart surgery as those who quit the habit. He said this lifestyle choice “should be taken into account” when deciding who was to be operated on.
He had, he said, seen a TV documentary a few years ago about women in Florida waiting for their third bypass surgery. They were complaining that the insurance company was trying to discriminate against them because they already had two operations and gone back to eating cream cakes. One said she wanted the surgery because until she had it she couldn’t have any more cream cakes.
“I’m deeply opposed to doing that [having equal access] if that’s the case,” he said.
He argued the focus should be on treating healthy people who would benefit most. “That means we have to take lifestyle choices to some extent into account,” he said.
Unless such decisions were made to treat some and not those who wouldn’t benefit, we would continue to have poor services, for example, for people with cystic fibrosis who, he said, die several years earlier than their counterparts in Northern Ireland. “That is a complete disgrace and something that should not have been allowed to happen, and it happened as a result of a refusal to look seriously at planning and prioritising the way we use resources,” he said.
Friends First economist Jim Power suggested people who behave irresponsibly should not enjoy the same access to healthcare as people who behave prudently. And in an environment where healthcare resources were limited, funds had to be prioritised for those in “genuine need” and on the basis of equity and fairness, he said.
Generally it was known he said that those who smoked, drank and engaged in risky behaviours like mountaineering were more likely to need health services but should they, he asked, be given the same access to healthcare as those who didn’t engage in risky behaviour? “I don’t believe on grounds of equity or fairness they should,” he said.
“Why should society pay for the predictable consequences of dangerous lifestyle choices? We need to ration scarce resources on the basis of genuine need.”
He said 7,000 people in Ireland died as a direct result of smoking-related illnesses each year and €900 million to €2.25 billion a year was spent on treating people with smoking-related illnesses here. These people were using up scarce resources and he argued the money could be better used – providing improved AE services for example for those who didn’t engage in risky behaviours.
Labour’s health spokeswoman Jan O’Sullivan strongly disagreed, saying it was a “dangerous proposition” to restrict access to healthcare on the basis of lifestyle choices. Who would decide what were good and bad lifestyle choices, she wondered. Would an individual with a job that involved sitting in a chair all day be denied equal access to healthcare because of their sedentary lifestyle or what about Peter Stringer? Should he, she asked, be denied the same access to healthcare as non-sporty types because he put himself in danger throwing himself at 23 stone men in Cardiff just over a week ago to help win the Grand Slam for his country?
Instead of a “food and fags police” that would prevent equal access to healthcare, what was required was real action to understand why certain people, especially poorer people, often adopt unhealthy lifestyles, she said.
The debate, chaired by Fintan O’Toole, was the first in the 2009 Pfizer Health Debates Series in association with The Irish Times. A show of audience hands after a lively debate and a questions and answers session ultimately determined that the motion should be overwhelmingly carried.