Sarah Chan: Remoralising health policy

The sub-theme of this inaugural Think About Health conference is on “The Remoralisation of Health Policy”, and day two of the event, held in Manchester on 4-5 April 2008, began with a paper titled just that, from Jonathan Montgomery.  For those (including myself) who may have been somewhat uncertain about what the remoralisation of health policy might entail or why it might be necessary, he started by demonstrating what he sees as the current de-moralisation of health policy and practice.

Jonathan sees it as the shift “from a discipline in which the moral values of medical ethics… are a central concern, to one in which they are being supplanted by an amoral commitment to choice and consumerism.  In other words… the morality is being taken out of medicine by legal activity.”   A few examples given by way of illustration: the importance of informed consent in medical treatment is supposed to reflect a focus on respect for the patient’s autonomy, but (Montgomery suggests) has become more about risk transfer and shifting responsibility or blame for potential adverse outcomes.  Similarly, the “choice” system currently proposed by the NHS, where patients are able to select their preferred health service provider, may increase autonomy but is driven not by moral values but by an agenda based on the quality and efficiency promoted by competition. 

In light of this disconnection between the ideas expressed in policy and practice, and the moral principles that are meant to underlie them, the relevance of moral considerations in debates over health policy is questionable – yet so many test cases are framed in terms of moral arguments.  The remoralisation of health policy, then, is necessary to enable a meaningful consideration of the legitimacy of enforcing moral values: not whether, for example, it would be right or wrong to allow euthanasia, but whether it is justified to enforce a particular notion of right or wrong by means of the law or policy that regulates the practice.

This question was thrown into sharp relief by the second speaker of the day, Baroness Ilora Finlay.  She delivered an uncompromising, but also passionate, insightful and at times moving account of “Decisions at the End of Life”, from her own experiences during an almost twenty-year history of work in palliative care medicine.  This, for me, was a surprise highlight: as a bioethicist, one is familiar with the usual philosophical considerations regarding euthanasia and the law and policy concerns, issues of legitimacy, worries about slippery slopes etc.  To hear how these play out in practice, from someone who has had to deal with real patients and real suffering over and again, was far more gripping than the autonomy/best interests/sanctity of life arguments I might have expected, looking at the title. 

Baroness Finlay did not stint from giving, at times, an almost uncomfortable – but necessary, for it made it more real to us – level of detail, for example in her descriptions and comparison of how physician-assisted suicide versus euthanasia is carried out.  Did you know, for example, that apple sauce is the best vehicle for the mound of crushed barbiturate tablets given at fifty times the usual therapeutic dose in PAS?  Apparently it hides the bitterness most effectively.  She also challenged many of the common (mis)conceptions about end-of-life treatment – for example, morphine: not necessarily as toxic at analgesic levels as many believe, and therefore not as pliable to being used for euthanasia under the doctrine of double effect (already a philosophical fiction).

Those involved with end-of-life decisions usually have a message, one way or the other, about the acceptability of euthanasia and of laws permitting it.  The Baroness was clearly opposed, and brought a wealth of evidence and experience to explain her position.  For me, though, the true interest was not in being swayed to one side or another, but in the difference in the way the debate was framed and the focus of the concerns: not an abstract discussion of autonomy and human dignity, but a compassionate account of actions driven always by caring for patients as best as possible, whatever that might entail.  Above all, it illustrated that the real concerns in practice, the questions faced by those working at the coalface of terminal care, are sometimes radically different to the sort of concerns addressed by theoretical philosophical considerations of end-of-life issues.  This served today (at a level more personal than usual when I say such things) to underscore the vital importance of listening to these voices and incorporating these perspectives into the discourse over end-of-life.