Once More unto the Breach of Covenant?

The “Military Covenant” is in the news again:

The government is failing to abide by its military covenant, medical experts who treat injured soldiers have said.

Leading professors in psychology and orthopaedics say the healthcare system is not providing veterans with the service they have been promised. […]

The moral obligation to treat veterans should not stop when service ends, the covenant states, saying veterans should receive priority healthcare from the NHS when they are being treated for a condition dating from their time in the armed forces.

The Covenant is set out here; most of it is pretty vague, and what isn’t vague is largely predictable in its tone.  In respect of healthcare, the relevant part is on p 6:

The 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. […]  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.

This, at first glance, seems to be saying that members of the forces, and ex-members, should be treated in the same way as everyone else, except that they shouldn’t.  (There’s a fuller version of the statement here.)  The Government repeats this confusing attitude elsewhere: its own website explains that

[i]t’s not about getting special treatment that ordinary citizens wouldn’t receive, or getting a better result. For those that have given the most, such as the injured and the bereaved, we do make an exception

But maybe that’s just a terminological infelicity.

The Covenant itself does not have the status of law (and even if it did, that wouldn’t make any moral difference, unless you happen to think that all law is de facto good law).  However, the Armed Forces Act (2011) does state that the Secretary of State must prepare and present before Parliament every year a report on the covenant; and, according to §343A(3),

In preparing an armed forces covenant report the Secretary of State must have regard in particular to—

(a)the unique obligations of, and sacrifices made by, the armed forces;

(b)the principle that it is desirable to remove disadvantages arising for service people from membership, or former membership, of the armed forces; and

(c)the principle that special provision for service people may be justified by the effects on such people of membership, or former membership, of the armed forces.

I posted a couple of times about the Covenant last time it was in the news (here and here); I was suspicious then of the idea that ex-servicemen should get any priority.  And I’ve not changed my mind.

It seems like a fairly straightforward matter to me: if someone is in medical need, then they ought to be provided with healthcare that is at least good enough, and we should probably be aspiring to better-than-good-enough, subject to constraints about just expenditure.  Does having acquired those needs while in the forces make a difference?  Not as far as I can see.

There’s a number of reasons for this.  One is that the risks that members of the service pay are not unrewarded or unexpected.  Whether or not you think that infantrymen are paid enough is a different matter; but the point would stand that people going into the forces are paid, and take the job voluntarily.  This means that attempts to justify prioritisation on the basis that it’s compensatory for some abnormal sacrifice that’s required, rather than taken on seem weak.  Things might well be different if members of the forces were conscripted.  In that case, they’d be forced to do something that they wouldn’t otherwise have done, and prioritisation might be presented as part of the way that that is “bought off”.  Noone currently serving in the UK Forces was conscripted.  (As an aside, as I understand it, the Covenant in its current form was an innovation of the Blair government.)

Of course, being in the Army is riskier than being a failed academic coasting towards retirement.  Let’s face it: most jobs are riskier than that.  (I once got a bit of a sore throat giving a lecture, but… meh.)  And that’s quite important.  There’s any number of people who put their welfare on the line in the course of their job.  Of course, it’s important that employers minimise risks, and pay at a rate that reflects those risks, and have insurance that can pay for what’s needed in the event of those risks being realised, and all the rest of it.  But these points apply to people who work in pot-banks just as much as they do to squaddies.  None of this seems to amount to a reason for prioritisation for NHS services.

“Ah, but people might join the Army out of a sense of duty to the Fatherland the community, and the community should recognise that.”  Perhaps.  I think that that’s not really all that admirable a line to take; by nature I’m suspicious of the God-Queen-and-Country crowd.  But cynicism aside, it might equally well apply to any number of jobs: most obviously, the same could be said for the police.  But it might also be said for other professions.  Imagine that someone has a sense of obligation to the community, which leads him to want to work in the service of the community in some way.  And imagine that, after reflecting on how his skills could best be put to use, he decides to become a medic, or to work for the Forestry Commission.  Both of these vocations bring elevated risk.  So if we’re going to say that people who incur elevated risk for the sake of the community are entitled to prioritisation, then we need to say that that priority should be granted to doctors and foresters and any number of others to the same extent.  Hell, it’d presumably apply to blood-donors, too.  But prioritisation that is so widely spread is not prioritisation in any particularly meaningful sense.  I don’t detect a doctors’ or foresters’ covenant.

(There’s a further complication: if people sign up to the Forces in order to discharge a perceived duty, it’s hard to see how having done so generates an entitlement.  If you’re repaying something you think you owe, you don’t get privileges for having repaid.  That’s not how duty works.)

And, of course, there’s plenty of people in need who’re in need for wholly contingent reasons: people are sometimes born with illnesses and disabilities, and are sometimes hit by buses, and are sometimes simply unlucky in some other way.  It’s not easy to see why they should lose places on the waiting-list because they’ve done nothing at all to earn their need, or any special treatment.  Indeed, we might be tempted to say that people who’ve been daft enough to take up a dangerous job ought to take responsibility for that choice and its consequences, and drop places to those who’ve done nothing to contribute to their own situation.

When it comes to the crunch, though, what really matters is medical need.  Faced with one person in need, and one person slightly less in need but who has been a soldier, it’d be indefensible to prioritise the latter because of his employment history.  One doctor faced with two identical patients and unable to treat both has to decide which to treat ought, I’d think, to toss a coin.  That‘s the fair way to decide.

What matters if someone is injured, or suffering from mental illness, or anything like that, is that they’re injured, or suffering from mental illness, or whatever – not that they’re a soldier who is.  The “subject to clinical need” criterion in the quotation above reflects that.  But if clinical need is decisive, then the whole appeal to the Coventant – even if we think (arguendo) that the Covenant is a good thing – is simply window-dressing or political posturing.

Which, let’s face it, it might well have been from the start.

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