Medicine and the Military Covenant

There’s been a lot in the news over the last couple of days about the Military Covenant, and how there’s a plant to give it a legal footing as part of the Armed Forces Bill.  Some of the reportage over the weekend suggested that there would be explicit prioritisation for members and ex-members of the forces in respect of healthcare.  In the document that was published yesterday (link to 1.4M .pdf file), that commitment seems to be moderated – which is a good thing (for reasons that are basically the same as I outlined in an earlier post).

But healthcare does get special mention in the document; and, though it’s too long a mention to do proper justice here, it is worth quickly noting the highlights – or, rather, lowlights.  It’s the sort of thing that seems designed to please the tabloid press, but which will, in practice, please noone – not people like me, who think that special pleading for the military is moral hokum, nor people who think that special provision ought to be made but won’t find it here.

The section concerning healthcare opens with the general statement that

[t]he Armed Forces Community should enjoy the same standard of, and access to, healthcare as that received by any other UK citizen in the area they live. For Serving personnel, including mobilised reservists, primary healthcare is provided by the MOD, whilst secondary care is provided by the local healthcare provider. Personnel injured on operations should be treated in conditions which recognise the specific needs of Service personnel, normally involving a dedicated military ward, where this is appropriate for them, and medical rehabilitation in MOD facilities. For family members, primary healthcare may be provided by the MOD in some cases (e.g. when accompanying Service personnel posted overseas). They should retain their relative position on any NHS waiting list, if moved around the UK due to the Service person being posted.

Veterans receive their healthcare from the NHS, and should receive priority treatment where it relates to a condition which results from their service in the Armed Forces, subject to clinical need. Those injured in Service, whether physically or mentally, should be cared for in a way which reflects the Nation’s moral obligation to them whilst respecting the individual’s wishes. For those with concerns about their mental health, where symptoms may not present for some time after leaving Service, they should be able to access services with health professionals who have an understanding of Armed Forces culture.

The first sentence of the first paragraph strikes me as being unobjectionable: members of the forces should enjoy the same level of healthcare as anyone else because the NHS is there for everyone.  What I don’t quite get is how this squares with the first sentence of paragraph two, which states that members of the forces should not receive the same treatment as everyone else, but should get priority.  And so this prompts a question: should we accept the first or second bit?

That’s actually quite easy to answer, because the second really is (at best) puzzling, but probably unjustifiable.  The puzzling bit comes in relation to the qualification “subject to clinical need”.  This seems to amount to saying that members of the forces should be given priority except where others are more needy – or, in effect, that they should get priority except where they shouldn’t.  That’s morally defensible, but pretty trivial, since clinical need is the main criterion that decides who gets what on the NHS anyway.  (Cost is another factor, but since that’s not mentioned here – there’s no indication that members of the forces are magically entitled to a higher cost/ QALY threshhold – I’m assuming that it’s not relevant; this is how it should be.)  It’s the clinical need qualification that’ll be most problematic to those who think that members of the forces should get priority: they won’t.  In all likelihood, the difference made on the ground will be minimal, since servicemen who had a great need would be treated with a higher priority anyway, and civvies whose need is greater would still trump them.  People on both sides of the debate can be expected to look at the commitment with equal puzzlement, each wondering why it was worth making.

Where the claim comes into its own is in relation to people who have identical clinical need; here, it seems to amount to the claim that members of the forces go to the top of the queue automatically.

For the life of me, I can’t see why.  Imagine that Smith and Jones have identical injuries and identical prognoses.  Both require surgery, but there’s only one surgeon; and the longer they have to wait for treatment, the worse their prognosis will become.  Smith’s was picked up in the course of active service, and Jones’ was picked up as a result of some civilian accident.  Obviously, one has to be treated first, and the other will have a less-good outlook as a result.  What I struggle to see is why the nature of their employment should be the criterion to separate them.  Why not toss a coin?  I accept that members of the forces put their health and lives at risk – but they do so voluntarily, and in return for pay; so compensation can’t be the issue.  Smith would have a greater reason to expect injury than would Jones; and yet he chose that kind of life.  Jones, by contrast, had no reason to expect the injury, and did not choose it.  So on that front, we might even be able to say that Smith is a lower priority, because his injury is linkable back to his own choices.  Granted, it’s not a strong link – but since Smith and Jones are ex hypothesi otherwise identical, we have to take whatever difference we can; and it’s so much the worse for Smith in this case.

So the opening of the second paragraph is, at best, in need of substantiation.  There’s no obvious reason to accept it, but there is a reason to think it unimportant and potentially unjust.

Much of what comes over the next few pages is detail about how the MoD organises healthcare for forces members, and there’s little that’s really of much interest ethically.  Mention is made of the provision of mental health services; but one would hope that similar services are made available outside of the forces, too.  There’s no mention of the forces getting priority here; if there is any de facto prioritising of the forces, then it’s so much the worse for the rest of us.  (If that is the situation, the government certainly shouldn’t be trumpeting the provision of minimal service to which all should have access to some people as a particularly praiseworthy policy.)  There’s also mention of the government working with organisations like Help for Heroes and the various service benevolent funds to provide recovery services – and while I have no love at all for organisations like HforH, government collaboration with charities is nothing new, and is to be applauded in many cases.  As long as this particular collaboration gets the same attention as collaborations with any other charity, then fine.

Things get a bit strange on p18, with the news that

[t]he Independent Medical Expert Group, set up as a result of the Lord Boyce Review of the Armed Forces Compensation Scheme recommended that veterans suffering serious genital injuries be guaranteed three cycles of IVF. The Government is committed to ensuring this recommendation is implemented.

Once again, I’m finding it hard to see why this proposal is justified.  I’m assuming – though it’s not explicit – that the seriousness criterion is supposed to be interpreted as “infertility-causing”.  But this just leaves open the question about why it is that people made infertile as a result of some injury incurred in the forces are to be treated differently from those who become infertile in the course of any other job, or as a result of any other accident, or as a result of simply being born that way.  If infertility is a problem, it’s a problem; I don’t see why infertility with a particular cause among a particular section of the population is worthy of special attention – even allowing that the capacity for genetic reproduction is important at all (which is far from a given).  One might wonder, by the same token, why mention isn’t made of surrogacy services and reimbursement of costs there.

“Every year,” says the document, “approximately 22,000 Armed Forces personnel leave Service and return to civilian life.”  Most – it continues –

do so without any difficulty. However, for others the transition is more difficult. Those who have been seriously wounded can face a lifetime of reliance on health and social care services. (p19)

Well, yes: but you don’t have to have been in the forces to face a lifetime of reliance on health and social care services.  It’s hard to object to dependent soldiers and ex-soldiers getting health and social care, and one would hope that they get more than the minimally decent provision.  But this has nothing to do with their career choice (and it is a choice – as another ethicist I know commented in a FaceBook post last night, “[the forces’] own recruitment literature emphasises the ‘this is a whizzo career! You can learn to cater and drive tanks!’ over the ‘we might ask you to die for your country’ bit”); it has to do with their being in need.  Once you’ve got your head around the need bit, the military bit seems to be unimportant.

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