Review

Live cheap, die cheap

STRONG MEDICINE
Paul Menzel
OUP, 1990

Obsessed with technology, many Americans try anything to beat death: indefinite intensive care, immediate heart transplant following cardiac arrest, major surgery for even the most hopeless terminal cases. But is some medicine just too expensive for the sake of some sorts of life? Should there be a limit on medical treatment?

In Strong Medicine Paul Menzel argues that if resources are scarce then limits have to be set, however unpalatable they might seem. Ideally consumers ought to be allowed to buy whatever medicine they can afford, in which case the main limit to medical treatment would be the size of a patient’s bank account. But such a system does not yet exist.

Even in America medical services are provided for some people according to need rather than means. Menzel calls this the result of muddled thinking by health care planners. He says they lack the psychological equipment to confront the obvious — that health care is no different to any other commodity service. Nobody thinks that everyone should have the same size house, so why should all citizens be entitled to equal amounts of health care?

Menzel believes some medical therapies cost more than some patient’s lives are worth. So the oldest, sickest patients should not be offered expensive state medical services. However, he recognises that squeamish doctors will still treat even the least worthy patients. Therefore if very sick people are offered expensive treatment they should have the ‘moral guts’ to refuse it. It is not heroism to cling onto life at any cost, but selfishness. The very ill are very costly. They have a duty to die cheaply for the community’s benefit.

The most twisted part of Strong Medicine considers whether it can be rational to offer the poor the same medical care as the rich. Menzel thinks not. Look at what poor people spend their money on — food clothes and beer, not medicine. Yet see how richer people spend — they prefer to take out medical insurance. Through their spending choices poor people demonstrate that they don’t want medical care, so to force it on them is insulting. Consequently it is immoral to offer health care equally to all.

It is not always moral to use scarce resources according to compassion for individual patients, but Strong Medicine offers an infinitely worse scenario. Menzel has penned a nightmarish vision of one possible future for the NHS. The book is not science fiction, but a dreadful warning against permitting politicians to override principle of care through idolatry of market forces. The most frightening aspect of this depressing book is not Menzel’s strange logic, nor even his conclusions. What is truly chilling is that other writers of fascist ethics are queuing up to beat him at his own game. They see that Strong Medicine has not gone far enough: if some people are too worthless to treat, and have a moral duty to die cheaply, then that duty exists whether or not they are ill. If you are too expensive to keep alive with medicine you are also too expensive to feed.

Strong Medicine is poorly argued, and in places plain evil. But it should be read, perhaps most of all by our own crusading health reformers. They should know what lies at the end of the road to economic enlightenment.