Fintan O'Toole: Skipping the vaccine queue isn't a breach of the health system, it's the system

On March 19th, Ireland got its first dedicated hospital clinic for treating what is commonly known as long Covid. The virus leaves many people who have recovered from its initial attack suffering a variety of chronic conditions. The new clinic will "offer much-needed care and support to these patients as they continue in their post-Covid recovery journey".

Except what it will actually offer is care and support to those patients who have the money to pay for private insurance. The clinic is not in a public hospital. It is in the Beacon Hospital in Dublin. I am sure it is an excellent facility, but let's not kid ourselves – the first test for entry is what Americans call the wallet biopsy. Open the Beacon's website and you will see prominently displayed in the top right corner a link called Pay a Bill.

Which puts into context the (entirely justified) outrage over the private hospital's decision to give spare vaccines to teachers at St Gerard's private school near Bray, which is attended by the Beacon CEO's children, and to staff and managers at Park Academy, which runs private creches used by Beacon staff. Those instincts go deep.

A few weeks ago, in Paul Howard's always brilliant Ross O'Carroll-Kelly satirical column, Sorcha admonished her daughter in relation to the Covid vaccine: "I hope we didn't raise you to believe that just because we live in a big house in Killiney, we should be allowed to use our money to skip the queue." Daughter Honor then replies: "We use our money to skip every other queue. Why should this one be any different?"

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It’s a good question and, as is so often the case, the gap between satire and reality is uncomfortably narrow. Why should access to one desirable health-related commodity be any different from all the others?

Core ethical principle

The vaccination programme is based on a core ethical principle: access to treatment according to social and medical need. You get vaccinated first because you’re more vulnerable. But that ethical principle has never applied in the Republic.

The Beacon openly advertises its services to “patients who would otherwise be subjected to a lengthy waiting time on public lists”. In Honor’s words, we use our money to skip the queue. That’s what “we” pay for. In theory, we’re all entitled to public hospital services. In practice, almost half of us have a financial jetpack that lets us zip over the endless traffic jam the other half is stuck in on its way to hospital.

As of the end of 2020, there were 2.31 million people with inpatient health insurance plans in the State. That’s 46 per cent of the population. Let’s not fool ourselves: we stump up this hard-earned cash because we want faster access to healthcare than the other 54 per cent gets.

The dark truth is that transparency and fairness are invasive viruses in our healthcare system

I use “we” literally. I’m part of this apartheid system. I use the public health system when I can and I know it’s mostly excellent – when you can get into it. I pay private insurance overwhelmingly for one reason: I’m afraid I won’t get care when I need it. Bluntly, I pay to skip the queue.

Anxiety overrides morality. I would guess that the vast majority of those who buy private insurance would agree in principle that medical treatment should be provided on the basis of health, not wealth. I’m sure most medical professionals would agree with that principle too.

Organised hypocrisy

But ours is a system of organised hypocrisy. The organisational principle is fear. If you don’t trust the public system to give you timely access to the care you need, bad health becomes like fire or flood – a risk you have to insure against.

This sets up the vicious circle in which we have trapped ourselves. Half of us buy insurance because of the weakness of public provision, which weakens it further, and so on.

This is wildly inefficient and irrational. But it’s also deeply corrupting. It creates and sustains a doublethink – healthcare must be allocated on the basis of need, except there’s a long queue and I need to skip it.

Then along comes a massive public health emergency in which, suddenly, fairness is everything. The health of everyone hangs on collective behaviour and collective consent. That consent in turn depends on our ability to trust that both treatment and vaccinations are allocated transparently and impartially.

But the dark truth is that transparency and fairness are invasive viruses in our healthcare system. We have built up herd immunity against them by organising medicine around profit and privilege.

This is not, for a moment, to deflect the need for individual accountability for the apparent misappropriation and misuse of scarce public resources by the Beacon.

But even if we did get that kind of personal accountability, we would be left with the question we love to evade: do we or do we not want medical need to determine access to care?

Beacons were traditionally lit either as celebrations or as warnings. We either celebrate the culture of entitlement and injustice illuminated by this seamy episode, or we heed the warning that a system that values the lives and health of some citizens over others corrodes public trust and corrupts common decency.