It having been a long time since my last post, and this being the season of good-will, I wasn’t going to comment on the government’s new policy of charging migrants for A&E services.  Noone needs that kind of spleen on a dreich Monday; besides: I’ve got a PhD thesis that needs assessing, and a bathroom floor that I’ve been meaning to re-lay all year – all manner of better uses of my time.

Still, there’s a couple of things that merit comment.  First, there’s this, from the Government’s press-release:

We know that some people are abusing the system by coming into the country early enough to have one or more antenatal appointments before giving birth on the NHS – without the intention to pay.

I love a good vague statistic.  “Some” people.  There’s nothing offered about how many that amounts to.  Presumably, it’s more than one, but fewer than everyone.  Beyond that, though… well…  The phrase “some” just isn’t very useful when it comes to making judgements about anything – as waitresses (and diners) can attest.  But still, I’m willing to concede that “some” indicates a positive integer, and that there is therefore some measurable impact on expenditure arising from such people.  This doesn’t tell us whether it’s expenditure at a level that should bother us.  The DoH press release offers some illumination on this point:

The announcement follows a Department of Health study which estimated that up to £500 million could be recovered from overseas visitors’ and migrants’ use of the NHS every year through better charging.

Blimey.  £500m, eh?  That is, I’ll admit, quite a lot, seen in absolute terms.  But absolute terms can be misleading.  Assuming a conservative estimate of the population of the UK at around 60m, that amounts to £8.33 per annum – or a little over 2p a day.  That’s hardly onerous.  Now, I’ll admit that there might be a problem in people being expected to pay £8.33 for anything when they don’t have to; but this isn’t money wasted: it’s a social good that’s being provided.  Moreover, the maths here assumes that the bill lands squarely with individuals – that companies don’t make any contribution at all.  But they do.  (I’ll admit that there’s a technical distinction to be drawn between tax and NI; but I think the general point that not all public spending is based on income from the likes of you and me stands.)  And anyway: according to the NHS Confederation,

The planned NHS budget for the 2012/13 financial year is £108.897 billion,

in the context of which, £5oom really isn’t all that much after all.

It seems pretty obvious to me that the move has less to do with saving public money – the press release, incidentally, is listed under the policy category Making the NHS More Efficient and Less Bureaucratic, because nothing increases efficiency and reduces bureaucracy like a needless entitlement test, duh – than it has to do with panicky politicking about Romanian and Bulgarians apparently “flooding” to the UK.  (They always flood in, don’t they, these forrins.  Never come alone, and never queue.)  But quite why emergency medicine should be on the list of things for which a charge is made is still a puzzle.  I mean, I can sort-of see how there might be a genuine problem with people nipping across for the sake of ante-natal care (assuming, of course, that the care you get in Birmingham is so much better than that you’d get in Bucharest that it’s worth a 1700-mile trip, which I find implausible).  But for emergency medicine?  If I break my leg, or lose feeling down my right-hand side, it’s unlikely that my first response would be to head for the airport.  Which means that people who present in A&E are in need right now.  They aren’t gaming the system.

Is there more to this than political exasperation?  I think that there is.  Richard Ashcroft wrote on a similar theme in 2005, suggesting that

when denial of medical treatment, even to people with genuine medical need, is being used as a lever to move people out of the country, ethicists and healthcare professionals should speak out. Systems which ensure poor quality or denial of service to one vulnerable group, merely pour encourager les autres, diminish and threaten us all.

This seems right.  The NHS is, among other things, a moral institution – by which I mean it’s based on a particular moral vision of healthcare being available and free at the point of need.

Now, that’s compatible with there being some finite entitlement.  There’s a difficulty in determining where that entitlement lies – why should a Bulgarian who’s been living in the UK for a while, paying taxes and contributing to the economy have to pay extra for a one-off accident to be fixed, when a severely disabled “native” newborn who has certainly not contributed yet, and may not contribute, gets treatment for free?  (Note to readers still jumpy about The Paper Of Which We Do Not Speak: I’m not saying that the latter should be denied treatment.  Only that, if we’re going to talk about entitlements, why shouldn’t they be based on contribution to the economy?  When it comes to that, some contribute more than others – yet we don’t ordinarily use that as a block on access.)

But even if we think that some people aren’t entitled to free treatment – let’s allow, for the nonce, that there’s a clear and non-arbitrary way to settle that – it wouldn’t follow that they shouldn’t get it.  On Twitter, someone called Nick Hopkinson complained about a

[d]ismal Tory mindset – focus on stopping a few getting what they’re ‘not entitled to’ rather than ensure the many have what they need.

And that’s important.  Just because someone isn’t entitled to something, it doesn’t follow that they shouldn’t get it.  I don’t think that Singer’s archetypal drowning child is entitled to be pulled from the pond; but it doesn’t follow that it’s OK to ignore her.  The duty isn’t of that sort.  The same sort of thing, it seems to me, applies here.  If there is a recognised duty to provide healthcare free at the point of need, it doesn’t arise as a way of meeting an entitlement.  If there’s entitlement at all, it’s created bt the duty.  (If there isn’t a duty to provide healthcare free at the point of need, of course, all bets are off.)

I think that this is a vaguely virtue-ethical point.  The honourable attitude isn’t constrained by rights and entitlements.  It’s bigger than that.  It’s what Aristotle would have termed megalopsukhia – greatness of soul.  And let’s not forget that, for Aristotle, ethics is a branch of politics.