The first London Intercollegiate Student Medical Ethics Debate took place at the Wellcome Trust on 28 March. Teams of three to four students from the London schools debated a range of ethical dilemmas in a knock-out ethics tournament. Teams were randomly allocated to argue for or against the motions. The winning team came from St George’s, University of London and we invited them and the other finalists, from King’s College London, to provide arguments for and against one of the scenarios used in the competition.
Juan (a non-UK resident) arrives in the UK. He is not eligible to stay in this country. He has some contacts in London and earns money through drug dealing. He has persistent back pain and finally attends a London A&E. He is diagnosed with renal failure and, although not in immediate danger, he is in need of ongoing dialysis. Juan is not eligible for NHS treatment and cannot afford to pay. Should Juan receive dialysis funded by the NHS?
JUAN SHOULD RECEIVE DIALYSIS FUNDED BY THE NHS
Guy Bower, Sharenja Jeyabaladevan, Vongai Madanire, and Alice Michell, St George’s University, London
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The duty of doctors to provide care for Juan is not negated by his immigration status or his occupation. It is unethical for doctors to discriminate against patients on the basis of their circumstances. Consequently, the fact that Juan has dealt drugs should not act as a barrier to treatment.
Nor should his immigration status stop him receiving treatment. Under government policy foreign nationals are only entitled to receive emergency treatment or treatment they can pay for.1 Although Juan’s condition is not a medical emergency, renal failure is life-threatening when untreated. It would be cruel to allow his health to deteriorate into an emergency and to only treat him then. This would be medicine dictated by government immigration policy, rather than clinical judgment.
Abiding by government policy and not treating Juan would also undermine the trust between doctor and patient. Illegal immigrants would not present to health services and this would lead to wider public health problems, especially in cases of infectious disease. Immigration policy cannot be completely ignored, but it should not be the doctor’s duty to police immigration.
Dialysis is expensive and issues surrounding fair allocation of resources are certainly worth considering. Who should be entitled to free British healthcare resources? What of financial aid sent to developing countries? It is not the job of doctors to pick and choose whom to treat at the hospital door.
To deny Juan available treatment would be ethically negligent and callous, and would undermine the non-judgemental, non-discriminative nature of the NHS.
JUAN SHOULD NOT RECEIVE DIALYSIS FUNDED BY THE NHS
Ishaac Awatli, Roxanne Keynejad, Daniel Thompson, and Mark Yao, King’s College London
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Nation states have a moral obligation to pursue national self-interest, namely the needs of their citizens.2 However, medical resource restriction based on national membership challenges the deeply embedded principle that no life is intrinsically more deserving than another. The difficulty for healthcare professionals is to juggle these two conflicting propositions.
We acknowledge the right of any patient to immediate life-saving treatment, since it is a justifiable presumption that human life supersedes financial concerns. However, Juan is not in immediate danger of dying. The appropriate action is, therefore, repatriation before commencing any medical intervention. This may betray the doctor’s instinct to alleviate suffering, but it is the most ethical action, given limited NHS resources.
Affording Juan dialysis undermines the rational imperative of a nation to protect its institutions, which requires restricted membership. Although determining entitlement via citizenship could violate migrants’ international human rights, it may be reconciled through a doctrine of realism. While Juan cannot individually damage the NHS, unregulated treatment of new arrivals to the UK has considerable, unsustainable costs. The precedent set is a very real danger, given the burden of national immigration. We must not jeopardise our national institutions with unrealistic notions of healing the globe.
Our hospitals are currently owed £40 million from foreign nationals.3 Within the current economic climate and widespread austerity measures, the principle of ‘treating everybody equally’ is naïve, unfeasible, and potentially divisive among tax-paying citizens. The NHS is under genuine threat: we must not further destabilise it by prioritising ethics we cannot afford.
- © British Journal of General Practice 2012