The paradox of promoting choice in a collectivist system.

I n both the policy and academic literatures, the issue of extending patient choice in the UK National Health Service (NHS) is currently a much discussed issue. From December 2005—for example, general practitioners (GPs) will be required to offer patients needing elective surgery the choice of five providers at the point of referral. Choice is often thought of as an intrinsically good thing; that is, that people value choice in and of itself. A probable underlying reason for this belief is that choice is tied in with the notion of individual autonomy, or freedom, a concept that looms large in ethical theories of the good. Beauchamp and Childress—for example, classified respect for autonomy—along with beneficence, non-maleficence and justice— as one of the four prima facie moral principles that most serious moral thinkers can agree upon, regardless of moral, religious, philosophical, cultural, and social background. The Beauchamp and Childress classification is instructive, as it recognises implicitly that unrestricted autonomy imposes the potential for negative externalities. Hence their requirement of non-maleficence. That is, people’s freedoms ought to be curtailed in those circumstances where they pose harm to others, a clause that if ignored may lead to the strong exploiting the weak. The discourse on choice in the NHS, in particular by those in favour of extending choice, tends to somewhat overlook the very real possibility that offering greater choice, which may prove costly to implement and administer, will ultimately serve to benefit some and harm others. Also, despite the proposal that offering greater choice could be targeted at those who have been disadvantaged historically, there seems to be little safeguard against the risk that those who are most advantaged in terms of education, income, and social position will benefit to the detriment of others from the choice proposals. Arguments for and against greater choice in the NHS can be related explicitly to the tension between collectivism and individualism. The principles underlying the NHS are collectivist, and are intended to secure access to health care services irrespective of the socioeconomic or demographic circumstances of the individual. The key to this system is that everybody be treated fairly given available resources. The system is unfortunately but inevitably resource constrained, since the government can only target a proportion of the nation’s wealth toward these services. If there were unlimited NHS resources, everybody’s preferences could be satisfied fully, and it would be possible to allow everyone free, extensive choice. In reality, it is necessary to accept that the NHS cannot provide everything that each individual patient may want. Although an individual patient may gain greater satisfaction from being offered more choice, the opportunity costs of extending choice to this patient, arising from the reductions in resources available to other patients, may be detrimental to the overall social good. The individual patient is a poor judge of the institutional resource constraints, and thus the notion of choice and its individualistic underpinnings is fundamentally inconsistent with the collectivist NHS ethos. Offering everybody a greater degree of control over what they receive will thus create winners and losers, which, in any universal health care system, may well be deemed unacceptable. Collectivism minimises the chance that there will be a large differential between the strong and the weak, but this requires social decision makers (rather than individual patients), in the form of a GP, a primary care trust (PCT), and/or the Department of Health, to determine a fair allocation of health care with reference to the system’s resource constraints. If we conclude that the system’s founding solidarity based principles remain relevant we might thus be better advised to place emphasis on protecting the decision making capabilities of those imbued with social responsibilities, rather than be guided increasingly by individual patient choice.