The Moral State We’re In

Secondly, it was argued that there has been a change in public opinion, particularly after the Diane Pretty case (Ms Pretty died in May 2002, three days after the European Court of Human Rights ruled that her husband could not legally help her to die). Thirdly, changes to the law in Belgium, Holland, and Oregon have apparently worked out well, with no real indication of the predicted dangers associated with assisted suicide actually materializing. For instance, the Dutch government’s Remmelink Report found no evidence of vulnerable people being put at risk or of increases in voluntary euthanasia in the previous five years. (It does have to be said, however, that supporters and opponents of the Bill infer different conclusions from international experience.)

Fourthly, people are able to travel to other countries, such as Switzerland, for assisted suicide, which those who support a change in the UK legislation regard as unreasonable. Fifthly, it gives choice to the patient rather than to doctors or society, a point made strongly by Baroness Flather. Indeed, the newly published Good Euthanasia Guide by Derek Humphry, a former Sunday Times journalist now based in Eugene, Oregon, suggests that personal choice is a powerful factor.

The main arguments made against the Bill were that there is still continued opposition from the British Medical Association (BMA) and the Royal Colleges, which is a real problem since a change in the law could only be effected with the support of doctors. Secondly, it was seen as ‘disastrous’ for ‘the terminally ill, the elderly, for disabled people, for the medical profession and for wider society’ by many peers, including Lord Alton of Liverpool, whose exact words are given here. Thirdly, it is seen as brutalizing society, with some drawing parallels with the death penalty and others arguing that the Bill would put pressure on all seriously ill people to consider assisted suicide, even if they had never previously considered such an idea.

Some argued that patients might feel obliged to choose assisted suicide for the ‘wrong reasons’, such as to avoid being a burden to others, or because of concerns about the financial implications for their families of a long terminal illness. Some also argued that it would create a ‘negative climate’ towards terminal illness, and that sick, disabled, and frail people might be made to feel even more acutely that they are a burden on society and on their relatives. Other objections centred on problems of definition: what is a terminal illness, particularly when some diagnoses prove to be incorrect and patients live much longer than predicted? Then it is often the case that seriously ill people are depressed, which might impede their ability to make rational decisions. Amongst the weightiest objections was the classic one from many healthcare professionals: that the legislation might affect patients’ trust in their physicians and thus alter the fundamental ethos of the medical profession–a view held by the BMA. Indeed, doctors generally remained opposed to the Bill.

Meanwhile, some argued that the proposed legislation placed too great a responsibility on doctors and that the benefits to the individual would be outweighed by the potential harm to society at large. Many also argued that the Bill was unnecessary because physicians can already relieve the pain of their patients, even if pain relief has the foreseen but unintended effect of shortening life. It was also suggested that the Bill would be impossible to police and would lead to more involuntary killings–the slippery slope argument. Then it was argued that such legislation would be seen as unacceptable to some faith communities and religious leaders: ‘Euthanasia is an act of violence, an attempt to take possession of the future…even if euthanasia were legalised in some form and pragmatic anxieties overcome, it could not be a course of action endorsed by Christians.’* (#ulink_a2e36ca9-d382-5a44-857e-0806f007299d) It was also argued that that the insurance industry would be unlikely to accept the provision that no life insurance that has been in force for twelve months would be invalidated by a doctor having assisted a patient to die. Lastly, it was argued that the Monitoring Commission proposed in the Bill would be costly and that it would be difficult, if not impossible, to detect subtle coercion, pressure, or clinical errors after the event.

These were the arguments put forward over the debate, the longest re-examination of attitudes to assisted suicide in the UK in recent years. Meanwhile, many key organizations put in their views at the same time. For instance, Help the Aged strongly opposed any change in the current law related to assisted suicide. It argued:

The prohibition on assisted suicide is designed to protect some of the most vulnerable members of society, including many older people. Any change in the law would run the risk of abuse and would fundamentally change the doctor/patient relationship. Planning and taking decisions around the end of a life are deeply personal issues and, like any other adult, older people have a right to retain control, autonomy and choice. This choice includes the right to choose to refuse medical treatment. All too often, older people who wish to exercise such control are denied the right to be involved in decisions about the end of their lives. This debate highlights the lack of clarity and safeguards around decision making for very vulnerable people who may be unable to make or communicate their own decisions at any stage of their treatment or care. Help the Aged calls on the Government to introduce legislation to strengthen and support older people’s ability to make decisions about their own care, to ensure that their wishes are respected, and to allow them to retain choice and control over their lives at every stage.* (#ulink_f7386aca-9782-5af6-8253-d2fa4b16533a)

At the same time, the National Council for Hospice and Specialist Palliative Care argued that:

The principles of palliative care affirm life whilst regarding death as a natural process to be viewed neither with fear nor a sense of failure. Death may be impossible to postpone but should not be hastened. Respect for the dignity of the individual is important, and regarded by many as paramount. Such respect is not manifest in the act of killing the patient which would merely serve to confirm the individual’s falsely devalued sense of self-worth. We recommend that there should be no change in the law to permit euthanasia.

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The Voluntary Euthanasia Society, unsurprisingly, supported Lord Joffe’s Bill, whilst the Disability Rights Commission opposed it, not on moral grounds, but because it believed that until disabled people are treated equally, with their lives accorded the same value as those of non-disabled people, their access to necessary services guaranteed, and their social and economic opportunities equal to those of non-disabled people, the ‘right to die’ legislation might jeopardize people’s right to live:

The bill would open the floodgates for people who are not just terminally ill but for those with long term physical illnesses to be helped to die. The safeguards included in the bill are simply not good enough to guard against many disabled people being included.

There is simply no system of safeguards that can detect the hidden pressures and strains from relatives and carers that may drive a disabled person to seek an assisted suicide.

The absence of support services on the ground and high quality palliative care means that there cannot be a real choice. In this context, rather than ensuring the right to die, the bill would quickly translate into a duty to die for disabled people.* (#ulink_38462b2c-57c4-53af-bdf4-793152c12937)

The Royal College of Nursing also came out opposing euthanasia and assisted suicide: ‘The RCN is opposed to the introduction of any legalisation which would place the responsibility on nurses and other medical staff to respond to a demand for termination of life from any patient suffering from intractable, incurable or terminal illness.’

(#ulink_41ade759-8249-5cf1-8684-9a59c9f37eb5) But that was not a totally universal view from the RCN. In a personal capacity, Karen Sanders, who chairs the RCN’s ethics forum stated: I feel strongly about euthanasia because I believe that competent adults who have incurable or insufferable diseases should have the right to make their own choices about their own lives.’

Despite those supporting or opposing Lord Joffe’s Bill who claim public opinion is on their side, it is actually extremely difficult to establish precisely what public opinion is on this issue. There is little independent information on how the public view assisted suicide, although it is clear that most major organizations concerned with the welfare of older and disabled people oppose changes to the current legislation. The Voluntary Euthanasia Society claims that 85 per cent of the population supports them, although it does not specify what, precisely, the support relates to or how it can be so sure. Many other polls ask questions that are so vague as to be almost worthless. For example, the Sun newspaper’s 1997 telephone poll asked whether terminally ill people should have the right to die with dignity; unsurprisingly, 97 per cent said yes. But the mood is shifting and Deborah Annetts, Chief Executive of the Voluntary Euthanasia Society, is right to argue that, as an increasingly secular society in which more people are living longer, our demography will itself be a catalyst for change.* (#ulink_9422ec3b-140b-50d8-8ca1-099b617c92cf)

Whilst all the debate around Lord Joffe’s Bill was taking place, the Christian Medical Fellowship recommended a letter-writing campaign for people to express opposition to the Bill, but it is not clear what the response to this was. An Independent on Sunday poll in 2001 asked, ‘Should people have the right to die when they choose?’ and found-unsurprisingly, given the vagueness of the question-that 85 per cent of respondents answered yes and 15 per cent answered no. Meanwhile, a survey by the Disability Rights Commission reported that 63 per cent of people felt there should be new laws to make euthanasia or assisted suicide legal. However, more than eight out of ten respondents said measures were needed to protect disabled people from the use of ‘do not resuscitate’ notices and the withholding or withdrawal of treatment.

Much of the debate in the media has related to people dying of ‘terminal illness’ such as cancer or motor neurone disease. It is not clear whether some of the common diseases of old age, such as heart failure, dementia, or strokes, or even the natural processes of ageing itself, are typically viewed as terminal illnesses. Consequently, with the exception of some age-related organizations such as Help the Aged, the possible implications for older people of proposed changes in the law are not addressed as frequently as those for younger people. Yet it is the fear of living after a massively disabling stroke, of being completely dependent and unable to exercise one’s autonomy, that has driven the Bill’s supporters to try to get legislation through. Despite the public discussion being focused to a considerable extent on younger people, support for this legislation is at least in part about the fear of being very old and dependent, in both existential and economic terms.

There is certainly an argument for personal self-determination, to allow older people, and others who are terminally ill, to decide when they have had enough. According to that view, it is morally acceptable, for old people-or anyone else, for that matter-to be able to decide they have had enough and to exercise their autonomy. Test cases suggest that the public is increasingly sympathetic to this argument. The classic example is the 1992 case of Dr Nigel Cox, who acceded to a patient’s request-he had known her well for years-to put her out of her misery. Though charged with homicide, he was not in fact convicted and it was clear that he had the support of the patient’s family. He was not ‘struck off the medical register but was required instead to go on palliative care training, the argument being that, with more specialized knowledge, he might have been able to improve his patient’s pain control.* (#ulink_740aaebd-3c49-51c1-9c25-cf41fe5037a5) There has also been major debate on these issues in the House of Lords (Select Committee on Medical Ethics.) But the arguments need spelling out.

First, it is one thing to kill oneself because one cannot bear to continue living. Suppose one were suffering unbearable pain, or extreme depression. Although it is terrible for those who are left behind, whose guilt is never assuaged because they feel they could have done more, there is a strong case for saying such suicides are not sinful. I say this despite the teachings of almost all the religious groupings. Historically, religions have argued that suicide is a sin. Those who committed suicide were often not buried in the same cemetery as those who died naturally; they might even be buried with a stake driven though their hearts, as consummate sinners. The argument was that God had given life and it was not for human beings to decide when life should be ended. Yet judicial killing was somehow permitted alongside this view, and the ‘just war’ was also permissible. So the logic barely stands up.

Japanese culture, and some others, have taken a different view in particular circumstances. Certainly there is also a strong argument for discouraging suicide. It is, after all, too easy to do, and the waste of opportunity, talent, and expectation is palpable. Nevertheless, with all the reservations about acute depression being a mental illness and the desire for suicide it sometimes engenders therefore being the result of an abnormal psychological state, it does have to be said that for some people life is intolerable. If that is the case, there may not be a strong argument to prevent them from committing suicide, or even for criticizing them posthumously if they succeed. In other words, there is a moral dimension to the argument that suicide, in these circumstances, is not necessarily wrong and that attitudes towards it should change.

It is therefore not necessarily wrong for someone to whom life has become intolerable, for instance through continual pain, to commit suicide. What is wrong is to expect them to do it in order to relieve the obligation of their care from their family or from society at large, or to ask someone else to help them to do it. And therein lies the rub, for it is not easy to commit suicide if one is already very frail. This might encourage people who had not yet reached this condition to contemplate suicide before they became too incapacitated to carry it out.

That is a problem answered to a considerable extent by the idea of having legalized euthanasia. Obviously real safeguards would have to be put in place. Doctors could not act without another doctor, or health professional, or some other person, witnessing the request and formalizing it in some way. People of sound mind would then be able to take control of their own lives and deaths. What argument can there really be against such a system, properly designed with protection in place for individuals and protection, legal and ethical, for health professionals?

The answer has to be that it is simply wrong to ask someone else to kill you. If an individual wants to commit suicide, sad though it is, that is understandable. One could even argue that it is their right to do so, especially if they are terminally ill already and however traumatic for everyone left behind. But to ask other people to do it for you, because you lack the determination or because you want to wait to the last possible moment when life seems truly to have nothing more to offer, seems very hard. Suicide may not always be wrong. But murder–even with the best of motives, and by request–is. The role of a doctor is to heal and to care, not to kill. Crossing that line is very difficult to justify. It asks doctors and other health professionals to go against everything they have trained for. However critical we may be of the tendency within our healthcare systems to preserve life in all circumstances, asking health professionals actively to seek the death of another human being is asking them to lose their respect for human life in a quite fundamental way.

Yet it appears that public opinion has gradually been moving towards favouring mercy killing. From the beginning of the 1990s, attitudes began to change in the Western world. According to polls carried out for the Boston Globe (November 1991 and onwards), 64 per cent favoured physician assisted suicide for those terminally ill patients who requested it. Of those under 35, 79 per cent were in favour. Question 119, the Washington initiative to legalize physician assisted death, was not in fact carried. But it raised questions about the role of doctors in keeping patients alive unnecessarily, and in an undignified way, as well as issues about whether it was a major conflict for physicians trained to preserve life to assist willingly and knowingly in procuring death. Yet the physician who assisted in the suicide of two women (painfully but not terminally ill), Dr Jack Kevorkian, who was arraigned on charges of murder but without specific charges being brought against him, had a preliminary ruling in his favour in Michigan in February 1992 and continued to ‘assist’ patients commit suicide thereafter. In the UK, we are beginning to see newspaper reports about people going to Switzerland to receive physician assisted suicide, because they cannot get it here. So the pressure is there. Many people want to be able to request euthanasia ‘when the time comes’.

Although there are considerable moral dangers in such a system, I believe that we will see limited euthanasia in Britain in the next decade unless a real moral debate takes place and those who are opposed to it argue hard against it. Even if this happens I believe that we will still see physicians being allowed to give terminally ill patients the wherewithal to commit suicide if they are convinced that this is what they want. The climate of opinion is changing. What we need to think about is to what extent this is because of people’s fear of growing old and helpless, their fear of the disintegration of self in old age, and society’s increasing unwillingness to accept that it has to pay for the care of the extremely frail and dependent.

Advance Directives

The arguments against the projected changes include, firstly, the view that asking doctors and nurses actively to kill patients is wrong and creates the wrong value system for a healthcare service of any kind. It may be the case that healthcare professionals do not need to strive to keep patients alive, but that is very different from actively killing their patients. Secondly, that suicide itself is not wrong and that an elderly or very frail person committing suicide is not necessarily to be disapproved of if it is done by their own hand rather than by another’s. Acceptance of this view should lead to a change of perception which might allow people to realize they can do it for themselves, and even be helped by being given the means in particular circumstances, without having to ask someone else actually to kill them. Thirdly, a rider to all this is the need for us as a society to develop a system of advance directives, whereby people can make choices for themselves about whether they want to be treated if extremely ill or when they can no longer make decisions for ourselves.

Such a system is in place in the USA. The PSDA (Patient Self Determination Act), a piece of federal legislation, came into force in December 1991. This requires all healthcare institutions, HMOs and services in receipt of federal funds to ask patients the question upon admission or enrolment about whether they have any kind of proxy or advance directive for what is to happen to them in the way of healthcare decisions if they become incompetent. At the same time, there is legislation in most US states that covers either healthcare proxies or advance directives, recognizing them in law and therefore in a sense approving their use.

There has been, rightly, increasing pressure to have a universal system of advance directives in the UK. The UK government has finally signalled, after a ten-year campaign, that there will be legislation to enforce so-called living wills via the draft Mental Capacity Bill, published in June 2004. This would apply both to those nearing their deaths, such as those who are frail and elderly, and to those who are or might become incapable for other reasons, such as those with enduring mental health problems, so that they can consent in advance to the treatments they might choose to have, or decide not to have, if they were well enough to make a decision. Some of the American evidence suggests that two separate factors are at work here. The first is a genuine desire to see self-determination for the very old. People must take responsibility for themselves, and must be encouraged do so before incapacity sets in. The other factor, which is certainly echoed in the UK debates, is the vast cost of paying for healthcare of the very old. The general view is that everything that can be done for a patient must be done, and there is a corresponding fear of being sued if any stone is left unturned, or any intervention left untried. If people could be persuaded to use advance directives, or appoint agents, there might be less use of expensive resources by the very old and very sick.

The fear of litigation in the USA is real and is growing in the UK. Though actual litigation is less common than the fear of it might suggest, it does have a powerful effect on behaviour. In the USA it is that pressure that has led to an increasingly strong argument for individual patients to have their own advance directives. State statutes on treatment directives give physicians a guarantee of civil and criminal immunity if they withhold or withdraw life-sustaining treatment relying in good faith on a patient’s advance directive. So, the argument runs, encouraging the use of advance directives will lessen the chance of litigation, allow for real patient autonomy, and arguably save costs.

But, if we are to move to a system of advance directives, then, as a society, we have to think quite differently about our health and social care systems. For the first time, with the exception of palliative care and hospice services, we will have to give far greater thought to the question of suffering, for despite the success of the hospice movement, suffering is barely part of medical training in Britain. Public debate on these issues needs to be encouraged, and public standards established. The idea that patients could set out for themselves, perhaps on a standardised form, what they want to happen if they are too frail, or mentally incompetent, to make a decision, is an attractive one. It would take away from healthcare professionals the need always to make decisions ‘in the best interests’ of the person involved, since it is often hard to tell what those interests might be. And many people simply do not want, at the end of their days, someone striving officiously to keep them alive.

Yet the system is not yet established that would allow us, as standard practice, to make our views known to our GP or to the person acting on our behalf in the healthcare setting. It is remarkably good practice at present if GPs and healthcare professionals ask us our views and make a note of them for future use. A system of advance directives seems sensible, practical, and easy to organize once a decision has been reached about what questions should be asked. The courts already recognize living wills, but the new mental capacity legislation will enshrine the right to draw one up in law and make it possible to appoint a healthcare proxy, in exactly the same way appointing someone to look after one’s financial affairs. As well as enshrining the right to make a living will in law, the Bill creates a new criminal offence of neglect or ill treatment of a person who lacks mental capacity, but it met criticism early on from the Making Decisions Alliance, a grouping of charities including Age Concern and the Alzheimer’s Society, who argued that the provisions lacked teeth and did not give advocates a central role in representing those affected by mental incapacity. In June 2004, the numbers affected were some 700,000 with dementia, some 145,000 with severe and profound learning disabilities, and some 120,000 suffering from the long-term effects of severe brain injury, quite apart from those with episodic severe mental illness.

At this point, it might be worth returning to the story of the donkey, the dog, the cat and the cock–all of whom had outlived their usefulness to their owners. Evidence is mounting of the rationing of healthcare by age in the United Kingdom. Is this because the elderly are seen as being too old to be productive? Or simply that they are felt to have had their turn and are taking up resources that should be used for younger people? A King’s Fund study in 2001 found that three out of four senior managers believed that age discrimination existed in some form or other in services in their local area. Discrimination included policies restricting access to particular units or treatments, although age-related policies were thought to be on the decline.* (#ulink_a6d0a798-b6cd-55d8-a404-e7816c94e626)

Discrimination and Rationing

The cost of caring for older people can only be contained if the general view is that it is morally right to do so, and that requires a public debate and a willingness to change on the part of the medical profession. Older people must not feel they are being denied care. But care in the future might be different from what they get at present. It could mean more palliative care for the relief of pain and suffering, more holistic and less scientifically driven care. Indeed, it might mean that care–rather than often futile attempts to cure–goes higher up the agenda.

This is the nub of one of the key issues facing the frail elderly and those of us concerned about their welfare. For what quality of life do patients enjoy after all the hi-tech healthcare? At present, nearly 29 per cent of all healthcare costs are concentrated on people in their last year of life (and, obviously, death rates rise with age). More dramatically, when looked at by age group, of all healthcare spending devoted to those aged 65–74, 43 per cent is devoted to those in their last year of life; for those aged 75–84 the figure is 56 per cent and for 85+ it is 65 per cent.* (#ulink_d47cb38a-8fd9-54a4-b7c1-a9ca57381d12)

It is hardly surprising that costs should be heavy in the last year of life, but if our true aim were to be the preservation of life at any cost, then we could certainly do more to keep old people alive than we do at present. For instance, are we keen to prescribe unpleasant chemotherapies for as yet incurable cancers, on the basis that our success rate is improving and one day they will work, as with the childhood leukaemias? Are we willing to say we will spend more on the life of a premature baby, a child or young person than on older people? Should we ration healthcare by age? Evidence exists for the rationing of care of people with coronary heart disease and cancer. Until recently, screening for breast cancer stopped at the age of 64. Now, women aged between 50 and 64 are routinely invited for breast screening every three years, and work has been carried out to extend the programme to women up to and including the age of 70 from the end of 2004.

One might argue that age criteria in breast screening have been in place because of lack of occurrence (in fact, incidence goes up with age) or because the life of a woman of, say, 70 who has advanced breast cancer has not been thought worth making an effort to save. Many experts argue that the cancer grows so slowly in older women that they will probably die of something else. But perhaps that is no longer the case with increased life expectancy. A woman of 70 is likely to be no longer economically active, yet it is also likely that she will be caring for an elderly husband or sibling–thus saving the state the cost of care. Is this not an economic activity? It may not increase GDP, but it certainly saves the state increased expenditure on social care.

The resource allocation arguments about rationing on the basis of age are well argued. The two positions are beautifully spelled out in the work of Professor Alan Williams of the Centre for Health Economics at the University of York, who is in favour of the use of age as a determinant for rationing decisions, and Professor Sir Grimley Evans, Professor of Clinical Gerontology at Oxford, who is strongly opposed. Williams argues* (#ulink_adcd5794-4d2a-5a95-ae30-f0fbcee370d9) that there is a vain pursuit of immortality (true) and that people over 65 are a far larger proportion of the population than they ever were. That is a point well taken. He argues that as we get older we accumulate a ‘distressing collection of chronic incurable conditions’. Some are a nuisance, but some are serious, involving disability and pain. Though most are incurable, that does not imply that they are untreatable. We also get more problems with acute conditions such as pneumonia and flu, and find it difficult to recover from what younger people take in their stride, like a fall. Hence healthcare expenditure on older people is comparatively so large.

Yet we know that much can be done for older people that is not hugely expensive, in terms of alleviation of symptoms and improving the quality of life in an unglamorous way. But, Williams argues, these unglamorous down-to-earth activities tend to lose out to hi-tech interventions which ‘gain their emotional hold by claiming that life threatening conditions should always take priority’. (This is, of course, a separate argument.) Taken to its logical conclusion, this would suggest that no one should be allowed to die until everything possible has been tried. That in turn suggests that we will all die in an intensive care unit (as many people in the USA do).

But this is not sensible. For all of us, there should come a time when we realize that a reasonable limit has to be set upon the demands we make of the system–and on our fellow citizens. What principles should determine that limit? Williams argues that the objective of the NHS should be to improve the health of the nation as a whole–the utilitarian argument. If that is so, then the people who should get priority are those who will benefit most from the resources available. So, if the concern is for the health of the nation, the older person is likely to lose out against the younger. If those are the values of the system, then the interests of a particular interest group are less important than the interests of the whole. So age will matter in two ways. It will affect the individual’s capacity to benefit from healthcare, making the relative cost of a procedure more expensive for older people, and it will incorporate the idea of a ‘fair innings’ by which older people are somehow thought to have had their share of living.

Grimley Evans* (#ulink_189b010f-487c-54d8-8f1f-8bc9f6098093) argues the opposite. He says that each of us should be treated as an individual. He argues it would be unacceptable to disadvantage people on the grounds of race, gender or national, or social origin. How, then, can it be justified on the grounds of age?

He then suggests it is easy to do so because older people in Britain, unlike in the United States, have not traditionally been organized politically. They rarely complain, refuse to pay their taxes, or cause riots. Militancy is virtually unknown amongst older people in Britain. Yet things may be changing, despite a slow start. Ageism remains legal thus far in the UK, and there is a growing body of evidence on age discrimination in a whole variety of services, particularly in health and social services as they affect the very old. Older people are beginning to complain. But Grimley Evans reserves his real scorn for prejudice. The old are seen to have less worth than younger people. Public attitudes in some surveys suggest this to be true. Survey interviews are rarely confidential. It is unlikely that people would say that one should discriminate on the basis of colour–even though there is racism in British society. But racism is publicly unacceptable. Ageism, on the other hand, is acceptable, and palpably so, and it is this that has led to a society in which there are so many frightened old people.

Grimley Evans then attacks the health economists. He suggests economists should restrict themselves to finding the most cost-effective way of distributing resources and that the ideology of efficiency, markets, and cost containment is no more valid than the ideology it replaced–of common purpose, collaboration, and social purpose. In the current NHS system one’s viewpoint depends on whether one is a user or a provider. The professional providers, one way and another, look for the best return on their investment of time and money. Users of the service, on the other hand, see the NHS as a sort of AA or RAC, there for use when they want/ need it. Citizens as taxpayers might agree with Williams, but British citizens as patients would ally themselves with service users, whose desire is to have their needs/wants met. Grimley Evans suggests that the users’ perspective provides a rationale more consistent with national values and with the explicit intentions of the NHS at its foundation. That is, in my view, having examined the earliest documents about the foundation of the NHS, debatable to say the least.

Do we then believe that all service users should be treated equally, however old? The measurement of outputs in units based on life years indirectly (or directly) puts different values on people according to their life expectancy. Older people are disadvantaged and, more generally, people are no longer reckoned equal. Secondly, the economists’ view assumes that the value of a life can be measured by its length. But if we assert the unique individuality of the person, then the only person who can put a value on a life is the person living it. Grimley Evans’ conclusion is that lives of people are not formally comparable; it is ‘mathematically as well as ethically improper to pile weighted valuations of them together as an aggregable commodity like tonnes of coal’. He continues by taking a swipe at nations who value their citizens only for their use to the state. Yet the NHS was at least in part set up to create that healthy workforce for the state, and people were not expected to live on into frail old age and lengthy retirement. He also suggests that the UK has a different set of values about individual human life from the economists’ outlook. He may be right, but it is as yet untested. He argues that we should not create, on the basis of age or any other characteristic over which the individual has no control, classes of untermenschen whose lives and well-being are deemed not worth spending money on.

But however the argument is played out, it has influenced older people. My father, who had his first heart attack at the age of 51 in 1965, survived to be 82. He was plagued with coronary heart disease for the rest of his life, but managed, despite a second coronary, to continue working until he was seventy years of age and to survive, with considerable determination, two coronary heart bypasses, one endarterectomy to prevent him having a stroke when the carotid artery became narrowed, and several other minor bits of surgery. Towards the end of his life, when he was over eighty, he would often say to me, as some other intervention or new drug was proposed, that perhaps he should not be having all this attention lavished on him. Yet he had a considerable quality of life. He carried on writing and thinking until just before he died. Determination made life, for him, very much worth living. And it did so for us, who did not want to lose him.

It is against that background that I think every day about the question of rationing on the basis of age. Can it be right? Is age the only determinant? Is it, indeed, a determinant of the kind of care one should receive? Pensioners make up a quarter of the bottom fifth of the income distribution. Householders aged 75+ are more likely to have housing that is unfit or substandard. Over 250,000 are on council waiting lists for sheltered accommodation. Isn’t the test of a civilized society not only how it treats minorities, but also how it cares for its older people who are dependent on it? Do we send them to the knackers’ yard, drown them in the well, cook them up for a stew like the cock? At least we’d get some last bit of use out of them. Or do we value them for who they are? Is there an inter-generational obligation?

Can we calculate what people should be entitled to? Should families have to look after their older relatives? What does that mean as families change? Should an ex-daughter-in-law look after her ex-parents-in-law? If so, this tells us a lot about older people and families generally. Can we judge other people’s families and what they do? Or is it a state duty to provide? Our four animals ended up living happily ever after in a house that had been taken by robbers, which they then took by force from them. We have no equivalent, unless we argue that being denied care when the NHS promised to look after them ‘from cradle to grave’ is a kind of robbery. But, whatever we feel about that analogy, the point has to be made that caring for older people properly is expensive. Someone has to pay, and it may be older people themselves. Even so, is it acceptable to treat them so poorly? Or is there truly a lesson to be learned from the Bremen town musicians: that older people will only succeed in getting decent care if they extract it by force? And what would that suggest then for the nature of our society, if groups had to become violent to get noticed?