The Northern Ireland Health minister was interviewed on the BBC here. After first saying that he didn’t want anyone in the health service to be put in a position of making ethical decisions to deny essential medical treatment the interviewer told him that the Chief Executive of the Belfast Health Service Trust has said that they are already being made, and are life and death decisions. Does Swann deny this or say he will investigate? No. He immediately and without hesitation attempts to justify something he said he didn’t want to happen, as if it hadn’t been happening.
He says that these decisions have to be made – “the ethical decision is could we turn a Covid patient away? The answer is no.” For other patients, “sorry your operation, your scope your diagnosis is going to have to be put off.”
When it is put to him that what he is saying is that a Covid patient won’t be turned away but that the result of this is that a cancer patient may die his answer is “yes, that’s as black and white as it is.”
So how is this ‘black and white’? There has been no medical assessment provided that this blanket prioritisation is justified, in fact it is presented as if its justification is self-evident, an obvious ethical decision. Except it’s not obvious and it is without justification, in both senses of that term – it has not been justified and any attempt to justify it would be wrong.
Swann says that we ‘cannot turn a Covid patient away’ but we already know that while over 50,000 people in the UK and over 3,000 in Ireland have died with Covid it is not at all clear how many of these have died of Covid. So how can this particular disease be prioritised?
More people die of cancer than Covid-19. There are around 165,000 deaths from cancer in the UK – that’s every year. In 2018 over 4,000 people died of cancer in Northern Ireland. In the Irish state over 9,000 die every year.
It cannot be because of the severity of the disease: cancer kills cancer patients because of their condition, while for most sufferers of Covid the disease is so mild they may not even know that they have had it. If someone with Covid has a serious underlying condition making them vulnerable to death compared to a relatively healthy person with the same disease, what is it that makes the difference between survival and death? Covid may be the proximate cause of death but Covid may not be the underlying condition without which death would not occur. If this is not considered an important distinction then presumably the health service and whole swathes of the economy will close down during the next flu season. A report from the Health Information Quality and Quality Authority shows that not all ‘Covid deaths’ should really be counted as such (see below).*
There is little that can be done to avoid many cancers; even those who don’t smoke, eat healthily and exercise fall prey to it. Hospital treatment is necessary but can sometimes require less serious intervention if caught earlier, although this is precisely what is being deprioritised. Those most vulnerable to Covid on the other hand can take many of the measures we have all become accustomed to including social distancing etc. The most vulnerable received shielding letters informing them of their vulnerability and measures they might want to take to limit exposure to infection. Swann and his chief medical advisor have decided that these letters aren’t necessary this time but provided no real explanation why. What has changed from the first lockdown?
Why is the protection of those most likely to suffer fatalities from Covid not the major focus of protection, support and prevention from these political leaders and bureaucrats? Is it not really that, what both measures have in common – prioritisation of Covid patients within hospital and lack of focus on those most vulnerable – and what is being protected, as they have made clear repeatedly, is the NHS? Protected from doing a job they know it will fail? And by their association, responsibility and accountability for it, protection of themselves?
The NHS in the North of Ireland is the worst in the UK. There are, for example, more than 2,500 nursing vacancies. As I have said before, Covid-19 may overwhelm the resources of the health service but is in itself not overwhelming. It is only so because the NHS is already in crisis, and what we are asked to do is also to accept that we must collude in covering up this permanent crisis, including through regular speeches telling us how difficult it has been for the staff.
This message is all the more powerful, and successful, because it is largely true – many health service staff have been under enormous strain but this should not be an alibi for failure of the bureaucracy that is the NHS as an organisation. As I have said before, the demand to protect the NHS, when it is supposed to be there to protect us, is an admission that this responsibility of the NHS will not be met.
The unjustified blanket prioritisation of Covid patients in hospital and the failure to issue shielding letters to the vulnerable are political decisions and have been successful because of a political campaign to justify lockdowns. This has involved not only politicians but also senior health figures, who have given legitimacy to their decisions. One such figure has been Gabriel Scally who has regularly intervened to argue that policies in the North and the South should be the same, as if two wrongs make a right. He has stated that ‘the figures speak for themselves’ when it is well know that they don’t, and has stated that over 50,000 have died of the disease without recognition that dying with it is not the same as dying of it. That such basic errors are repeated by a respected public health doctor illustrates the scope of the group think that has developed.
So egregious was the Health minister’s statement that the Department of Health put out a tweet entitled ‘Myth Buster’ with ‘myth number 1′ being “are Covid-19 patients being prioritised over other patients?” To which the answer was “No, they are not. Patients are treated according to clinical priority.” Swann pitched in with “it is untrue and offensive for anyone to accuse frontline staff of prioritising one condition over another.”
Since it was Swann who said that prioritising was ‘black and white’ perhaps it is himself he is referring to as being offensive. So who is right – the Department or the minister, and which version of the minister?
It would be difficult to deny that senior health staff would not be so stupid to as to admit such crass medical practice but easy to understand how Stormont politicians could grandstand with this level of idiocy and ineptitude.
The real problem is not that some politician has instructed hospital doctors to relegate individual cancer patients in order to prioritise Covid patients but that this is what has and will continue to happen by political decisions on allocation of resources that constrain individual medical assessments. These individual decisions rely on higher level decisions on allocation of staff, wards and beds to deal with Covid that in the first wave witnessed empty Covid beds in the Nightingale hospital while other treatments were stopped.
Lockdown is a political decision involving an analysis not only of the disease but the potential impact of the response. It is not a question of medical expertise determining the correct approach, even if one were naïve enough to believe that the medical profession is a paragon of virtue and wisdom. The advocates of lockdown refer regularly to the number of cases, hospitalisation cases, numbers in ICU and deaths but rarely to the costs incurred by lockdown. To do so would invite a critical debate they are ill prepared to have. Swann’s mistake was to take soundbites to their logical conclusion and blurt it out. It denotes the logic of the current approach but too crudely expresses its effects.
It is tempting to see in Swann’s first statement the chaos and breakdown of the functioning of the Stormont Executive that because of its reaction to the pandemic was seen for a while as an example of the political arrangements working. No one is pretending they’re working now. However, the real political weakness lies not in the political primitiveness of Stormont but that such crass political interventions elicit no popular opposition. Unfortunately on this score looking for the left to offer one would be a complete waste of time, as we shall look at in the next post.
* HIQA: ‘The officially reported COVID-19 deaths may overestimate the true burden of excess mortality specifically caused by COVID-19. This may be due to the likely inclusion within official COVID-19 figures of people who were known to be infected with SARS-CoV-2 (coronavirus) at the time of death who were at or close to end-of–life independently of COVID-19 or whose cause of death may have been predominantly due to other factors.’