{"id":2849,"date":"2014-10-31T16:44:59","date_gmt":"2014-10-31T15:44:59","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=2849"},"modified":"2014-10-31T16:44:59","modified_gmt":"2014-10-31T15:44:59","slug":"once-more-unto-the-breach-of-covenant","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2014\/10\/31\/once-more-unto-the-breach-of-covenant\/","title":{"rendered":"Once More unto the Breach of Covenant?"},"content":{"rendered":"<p>The &#8220;Military Covenant&#8221; is <span style=\"color: #0000ff\"><a style=\"color: #0000ff\" href=\"http:\/\/www.bbc.co.uk\/news\/uk-29807947\">in the news again<\/a><\/span>:<\/p>\n<blockquote>\n<p id=\"story_continues_1\" class=\"introduction\">The government is failing to abide by its military covenant, medical experts who treat injured soldiers have said.<\/p>\n<p>Leading professors in psychology and orthopaedics say the healthcare system is not providing veterans with the service they have been promised. [&#8230;]<\/p>\n<p><span class=\"Apple-style-span\">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.<\/span><\/p><\/blockquote>\n<p>The Covenant is set out <span style=\"text-decoration: underline\"><span style=\"color: #0000ff\"><a style=\"color: #0000ff;text-decoration: underline\" href=\"https:\/\/www.gov.uk\/government\/uploads\/system\/uploads\/attachment_data\/file\/49469\/the_armed_forces_covenant.pdf\">here<\/a><\/span><\/span>; most of it is pretty vague, and what isn&#8217;t vague is largely predictable in its tone. \u00a0In respect of healthcare, the relevant part is on p 6:<\/p>\n<blockquote><p>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. [&#8230;] \u00a0Veterans 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.<\/p><\/blockquote>\n<p>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&#8217;t. \u00a0(There&#8217;s a fuller version of the statement <span style=\"text-decoration: underline\"><span style=\"color: #0000ff\"><a style=\"color: #0000ff;text-decoration: underline\" href=\"https:\/\/www.gov.uk\/government\/uploads\/system\/uploads\/attachment_data\/file\/49470\/the_armed_forces_covenant_today_and_tomorrow.pdf\">here<\/a><\/span><\/span>.) \u00a0The\u00a0Government repeats this confusing attitude elsewhere:\u00a0<span style=\"text-decoration: underline\"><span style=\"color: #0000ff\"><a style=\"color: #0000ff;text-decoration: underline\" href=\"https:\/\/www.gov.uk\/government\/policies\/fulfilling-the-commitments-of-the-armed-forces-covenant\/supporting-pages\/armed-forces-covenant\">its own website<\/a><\/span><\/span>\u00a0explains that<\/p>\n<blockquote><p>[i]t\u2019s not about getting special treatment that ordinary citizens wouldn\u2019t 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<\/p><\/blockquote>\n<p>But maybe that&#8217;s just a terminological infelicity.<\/p>\n<p>The Covenant itself does not have the status of law (and even if it did, that wouldn&#8217;t make any moral difference, unless you happen to think that all law is <em>de facto<\/em>\u00a0good law). \u00a0However, 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, <span style=\"color: #0000ff\"><a style=\"color: #0000ff\" href=\"http:\/\/www.legislation.gov.uk\/ukpga\/2011\/18\/crossheading\/armed-forces-covenant-report\/enacted\">according to \u00a7343A(3)<\/a><\/span>,<!--more--><\/p>\n<blockquote>\n<p class=\"LegClearFix LegP2Container\"><span class=\"LegDS LegRHS LegP2TextC1Amend\"><span class=\"LegAmendingText\">In preparing an armed forces covenant report the Secretary of State must have regard in particular to\u2014<\/span><\/span><\/p>\n<p class=\"LegClearFix LegP3Container\" style=\"padding-left: 30px\"><span class=\"LegDS LegLHS LegP3NoC1Amend\"><span class=\"LegAmendingText\">(a)<\/span><\/span><span class=\"LegDS LegRHS LegP3TextC1Amend\"><span class=\"LegAmendingText\">the unique obligations of, and sacrifices made by, the armed forces;<\/span><\/span><\/p>\n<p class=\"LegClearFix LegP3Container\" style=\"padding-left: 30px\"><span class=\"LegDS LegLHS LegP3NoC1Amend\"><span class=\"LegAmendingText\">(b)<\/span><\/span><span class=\"LegDS LegRHS LegP3TextC1Amend\"><span class=\"LegAmendingText\">the principle that it is desirable to remove disadvantages arising for service people from membership, or former membership, of the armed forces; and<\/span><\/span><\/p>\n<p class=\"LegClearFix LegP3Container\" style=\"padding-left: 30px\"><span class=\"LegDS LegLHS LegP3NoC1Amend\"><span class=\"LegAmendingText\">(c)<\/span><\/span><span class=\"LegDS LegRHS LegP3TextC1Amend\"><span class=\"LegAmendingText\">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.<\/span><\/span><\/p>\n<\/blockquote>\n<p>I posted a couple of times about the Covenant last time it was in the news (<span style=\"text-decoration: underline\"><span style=\"color: #0000ff\"><a style=\"color: #0000ff;text-decoration: underline\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2010\/02\/10\/parachuting-to-the-front-of-the-queue\/\">here<\/a><\/span><\/span> and <span style=\"text-decoration: underline\"><span style=\"color: #0000ff\"><a style=\"color: #0000ff;text-decoration: underline\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2011\/05\/17\/medicine-and-the-military-covenant\/\">here<\/a><\/span><\/span>); I was suspicious then of the idea that ex-servicemen should get any priority. \u00a0And I&#8217;ve not changed my mind.<\/p>\n<p>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. \u00a0Does having acquired those needs while in the forces make a difference? \u00a0Not as far as I can see.<\/p>\n<p>There&#8217;s a number of reasons for this. \u00a0One is that the risks that members of the service pay are not unrewarded or unexpected. \u00a0Whether or not you think that infantrymen are paid enough is a different matter; but the point would stand that\u00a0people going into the forces are paid, and take the job voluntarily. \u00a0This means that attempts to justify prioritisation on the basis that it&#8217;s compensatory for some abnormal sacrifice that&#8217;s required, rather than taken on seem weak. \u00a0Things might well be different if members of the forces were conscripted. \u00a0In that case, they&#8217;d be forced to do something that they wouldn&#8217;t otherwise have done, and\u00a0prioritisation might be presented as part of the way that that is &#8220;bought off&#8221;. \u00a0Noone currently serving in the UK Forces was conscripted. \u00a0(As an aside, as I understand it, the Covenant in its current form was an innovation of the Blair government.)<\/p>\n<p>Of course, being in the Army is riskier than being a failed\u00a0academic coasting towards retirement. \u00a0Let&#8217;s face it:\u00a0<em>most<\/em> jobs are riskier than that. \u00a0(I once got a bit of a sore throat giving a lecture, but&#8230; meh.) \u00a0And that&#8217;s quite important. \u00a0There&#8217;s any number of people who put their welfare on the line in the course of their job. \u00a0Of course, it&#8217;s important that employers minimise risks, and pay at a rate that reflects those risks, and have\u00a0insurance that can pay for what&#8217;s needed in the event of those risks being realised, and all the rest of it. \u00a0But these points apply to people who work in pot-banks just as much as they do to squaddies. \u00a0None of this seems to amount to a reason for prioritisation for NHS services.<\/p>\n<p>&#8220;Ah, but people might join the Army out of a sense of duty to <del>the Fatherland<\/del> the community, and the community should recognise that.&#8221; \u00a0Perhaps. \u00a0I think that that&#8217;s not really all that admirable a line to take; by nature I&#8217;m suspicious of the God-Queen-and-Country crowd. \u00a0But cynicism aside, it might equally well apply to any number of jobs: most obviously, the same could be said for the police. \u00a0But it might also be said for other professions. \u00a0Imagine 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. \u00a0And 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. \u00a0Both of these vocations bring elevated risk. \u00a0So if we&#8217;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\u00a0foresters and any number of others to the same extent. \u00a0Hell, it&#8217;d presumably apply to blood-donors, too. \u00a0But prioritisation that is so widely spread is not prioritisation in any particularly meaningful sense. \u00a0I don&#8217;t detect a doctors&#8217; or foresters&#8217; covenant.<\/p>\n<p>(There&#8217;s a further complication: if people sign up to the Forces in order to discharge a perceived duty, it&#8217;s\u00a0hard to see how\u00a0having done so generates an entitlement. \u00a0If you&#8217;re repaying something you think you owe, you don&#8217;t get privileges for having repaid. \u00a0That&#8217;s not how duty works.)<\/p>\n<p>And, of course, there&#8217;s plenty of people in need who&#8217;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. \u00a0It&#8217;s not easy to see why they should lose places on the waiting-list because they&#8217;ve done nothing at all to earn their need, or any special treatment. \u00a0Indeed, we might be tempted to say that people who&#8217;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&#8217;ve done nothing to contribute to their own situation.<\/p>\n<p>When it comes to the crunch, though, what really matters is medical need. \u00a0Faced with one person in need, and one person slightly less in need but who has been a soldier, it&#8217;d be indefensible to prioritise the latter because of his employment history. \u00a0One doctor faced with two identical patients and unable to treat both has to decide which to treat ought, I&#8217;d think, to toss a coin. \u00a0<em>That<\/em>&#8216;s the fair way to decide.<\/p>\n<p>What matters if someone is injured, or suffering from mental illness, or anything like that, is that they&#8217;re injured, or suffering from mental illness, or whatever &#8211; not that they&#8217;re a soldier who is. \u00a0The &#8220;subject to clinical need&#8221; criterion in the quotation above reflects that. \u00a0But if clinical need is decisive, then the whole appeal to the Coventant &#8211; even if we think (<em>arguendo<\/em>)\u00a0that the Covenant is a good thing &#8211; is simply window-dressing or political posturing.<\/p>\n<p>Which, let&#8217;s face it, it might well have been from the start.<!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>The &#8220;Military Covenant&#8221; 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. [&#8230;] The moral obligation to treat veterans should [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2014\/10\/31\/once-more-unto-the-breach-of-covenant\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[968,511,475,1544,472],"tags":[],"class_list":["post-2849","post","type-post","status-publish","format-standard","hentry","category-clinical-ethics","category-in-the-news","category-politics","category-the-nhs","category-thinking-aloud"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Once More unto the Breach of Covenant? - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2014\/10\/31\/once-more-unto-the-breach-of-covenant\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Once More unto the Breach of Covenant? - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"The &#8220;Military Covenant&#8221; is in the news again: The government is failing to abide by its military covenant, medical experts who treat injured soldiers have said. 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Leading professors in psychology and orthopaedics say the healthcare system is not providing veterans with the service they have been promised. 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