Feature

Who killed Harry Elphick?

Whose fault is it when a middle-aged smoker is refused heart surgery? Steve Iliffe reports from the ethical front line

Harry Elphick, the 47 year old man refused cardiac surgery for advanced heart disease until he stopped smoking, died on a waiting list of potentially infinite length.

Before he died, he complained that his entitlement to treatment was being denied because the specialist had to ration resources. The specialist, in response, argued that the decision was a clinical one. Because resources for cardiac surgery were limited they had to be targeted at those whose benefit would be greatest. Why treat someone who would soon become ill again through their own actions?

Mr Elphick was bitter: he had paid taxes all his life only to be refused treatment when he needed it most. At his death he was caught between the irresistible force of the new individualism and the immovable object of collectivist illusion. To the specialists, his smoking was a matter of personal choice and he had a major responsibility in maintaining his own health. To Mr Elphick, the NHS was a powerful technological force on call for when he might need it, a kind of RAC for human bodies.

The specialists thought that Harry was - or should be - an active participant in his own medical care. His supporters felt he had paid enough in to the NHS to warrant making a withdrawal, and as the customer, he should always be right.

He was a consumerist, brought up by the welfare state to believe in an entitlement that carried no personal responsibilities, and he was a Cartesian thinker - of the best medical kind - who defined himself as separate from his body. No wonder he felt bitter when he took his body for repair, only to find that the mechanics had become converts to DIY maintainance without telling anyone.

He had misunderstood the purpose of all that tax he had paid: it had been entirely for others and not a personal savings account after all. Redistributive tax takes from the well to give to the ill, but decisions about who is well and who is ill are made by professionals. This is how the NHS has been ever since 1948, and there is little evidence of change except at the margins.

When he was well Mr Elphick had no reason to worry that such decisions lay with professionals. He probably believed, quite wrongly, the myth that the NHS provides for all according to need. Only those who work in it, or use it enough to encounter the hidden rationing, would think differently.

Nowadays, what was once coded in medical notes or in whispered conversations at the end of the bed is made explicit in the letters sent to people like Harry Elphick. A spirit of openness - prompted no doubt by shortage of resources - reveals the inner workings of nationalised medicine.

But the specialists are not playing God, for He would offer the odd miracle to those waiting for relief from their fear and pain. No, they are playing triage - matching resources to casualties, saving those with reasonable prospects and ignoring those beyond help. Doctors, with the right class attitudes and military bearing, play this part well.

Only those who can pay escape triage. Go to casualty and you will meet the triage nurse before you see anyone else. She will decide on your priority for treatment. Be referred to a specialist and have your referral vetted by clerks for residential eligibility, by middle managers for contractual coverage and by clinicians for urgency, while you wait in ignorance.

And very sensible too, since otherwise the worried well and the pushy middle classes would elbow the uncomplaining ill out of the queue. But it does not look sensible when it is your life at stake, and you suddenly find that you do not even know, let alone write, the rules.

In the good old days before Thatcher, the old, the mentally ill and the disabled had the ‘Cinderella’ services: shabby back wards in isolated hospitals, physical and emotional abuse, neglect. Although children in hospital were fought for by their parents, and women resisted the mechanisation of obstetrics, putting medicine on the defensive, those without power endured triage-by-default.

Now the old ways have been swept aside by market mechanisms that are supposed to solve all our problems. Those who did not notice that they had no real power over what went on are now discovering the meaning of that powerlessness. The benign dictatorship of the public services has lost its charm, and the comfortable illusions of the welfare state are melting into the market dawn.

This is the final irony. When, in 1987, a premature baby died for lack of special care the press knew who to blame. When Harry Elphick died there was very little certainty about the villain. Somewhere Conservative politicians are celebrating their success. Whoever was responsible for Harry Elphick’s death, it was not a member of the Cabinet. It may have been bad managers or it may have been bad doctors- or it may even have been Harry himself.