|PIC1|If there is one practical lesson I have learned in over 40 years of public life and ministry it is to be extremely wary of entering the corridors of another discipline with an attitude which says : "Let me comment on your work." It is all too easy to make assumptions and even offer so-called objective judgements from the touchline. Equally it is less than useless to offer bland remarks which amount to idle flattery. Such were just some of the danger signals confronting me when I was invited to deliver this lecture. Nevertheless alongside my genuine appreciation of the invitation does lie a deep sense of admiration and gratitude for all involved in the health services and health professions. Over those years I have seen at first hand their skill and professionalism and as a parish priest in this area admired the work of the Ulster Hospital on many occasions. But I am also conscious that at this time the whole area of health service provision and the exercise of those same qualities of excellence are being subjected to levels of scrutiny, examination and judgement without precedent. Such examinations varying from issues of financial support to comments from the society which benefits from that professionalism that are not always informed or helpful. Lurking behind both is the threat of a litigation conscious society which claims it knows it rights as never before.

I am reminded of two quotations which take this scenario from the sublime to the ridiculous. There was the reported remark in 1989 of the Department of Health and Social Services official in London who had recently transferred from the Foreign Office : "Dealing with doctors is even worse than negotiating with the French." Then there was the quotation from the NHS Management Inquiry of 1983 : "If Florence Nightingale were carrying her lamp through the corridors of the NHS today she would almost certainly be searching for the people in charge ..."

I recognise that for many of you here today debates on the finer points of ethics is not necessarily an everyday experience. You bring your expertise to bear on the actualities of illness or disability and you are absorbed by the pressures of those tasks. However we live at a time when more and more of us are being compelled to confront serious questions involving ethical judgements about the 'why' and the 'how' of what society is all about. Health care is now a priority issue for society. Not only politicians but ordinary people doing ordinary things are making it so. In consequence within the restless sea of ethics questions about moral decisions to do with health care are confronting us at an every increasing rate.

The truth is surely this : our society has developed an inherent assumed right to demand from the caring professions a level of service, a transparency of delivery and an abundance of availability which is not always aligned to reasoned, responsible or informed criteria of demand. Things are being demanded of right without the same willingness to provide what is necessary to deliver those services. A society which is making those demands is equally living through a period when consumerism is erecting many temples in which worship is geared above all else to incessant demand, incessant access and incessant value judgements which emphasise rights above responsibility and self-advancement above corporate wellbeing. I recall the remark of Tony Blair in 2002: "Customer satisfaction has to become a culture, a way of life, not an added extra."

What makes ethical or moral comment on health issues today even more difficult is that there are few issues in this area which can be addressed in isolation or on traditional ethical principles alone. There over-shadows most of these issues the question of finance. Almost all major health authorities find clear problems when they look to their budgets. Here in Northern Ireland it is questionable if even the reforms planned under the Review of Public Administration are likely to make sufficient savings to counter shortfalls for Health Trusts. Whether we argue that under-funding or overspending is the reason, rationing will be a feature for years to come. Rationing as I hope to show later is basically a moral decision.

Let me assure you health funding is not just an issue in Northern Ireland. From Canada the writing of John Ralston Saul makes the argument that emphasis on the individual in society and laws about equality of opportunity are not a moral defence to the reality of inequality or the need to make provision as a society for our weaker or more vulnerable members.

Current economic wisdom also leans towards the market-driven, consumer-driven, low tax economy as a sustainable model for growth and this again assumes that each individual is equally able to earn and make provision for their own health care well-being. As well as the obvious conflict between a low tax regime and provision of public services, reduced services result in an assumption that many people will 'top-up' through private insurance. When we remember that we pass through many stages of life - infancy and childhood, illness, disability, ageing - such stages make constant provision impossible except for a few members of society.

So, if this analysis is correct in any way it leads us to the conclusion - scarcity underpins may of the moral judgements necessary in medicine today.

So it is before this tapestry of contradictions that I invite you to reflect on a small part of what I term the 'stormy seas' of ethics in health care. As a society develops its norms of behaviour so it writes new agendas for ethical judgement and at the same time writes new scales of values. It also gives new importance to the old phrase - 'the devil lies in the detail.'

What then can we say today about how ethical judgement contributes to our understanding of public health issues?

Sir Donald Acheson described public health as :

"the science and art of preventing disease, prolonging life and promoting health through organised efforts of society."

The Institute of Public Health in Washington D.C. defines it as :

"what we, as a society, collectively do to assure the conditions for people to be healthy."

Both these views imply what must seem obvious - a distinct relationship between the values and efforts of society and the delivery of public health.

What is new about these ethical statements?

There has been the growth of an individualist society and a "rights-driven" society. That society is making constant demands on a system without at the same time contributing in return. There is, we are told, a lack of blood donations, organ donations and people are more and more unwilling to give up their time as volunteers. Again individuals are gaining more and more information about their own health and are educated and encouraged to make choices about their life-styles : there is the new interest of the media in health protection and means of providing the healthy life-style. However a preoccupation with autonomy and personal choice leads many people to resent any sort of state interference in how they live their lives : there are warnings about a "nanny state" that tells them what they can or cannot do : there are warnings on cigarette packets, proposed warnings on safe alcohol consumption levels on bottle labels and parliamentary debate on how to address drug misuses. In terms of ethics all this compels the public health service as well as the community to weigh up at what point personal choice outweighs the greater good.


Let me illustrate this issue from near at home.

The ban on smoking in the Republic of Ireland and a similar ban due to come into force in Northern Ireland in April 2007 can be justified in the interests of the general public and non-smokers - but they do not make illegal the act of smoking. It is a case of restrictions rather than prohibitions. People still have the right to make a choice. They can be warned of health hazards - but remain free to exercise individual choice. The student of ethics can well ask should society allow such freedom of choice? There is still the element of choice for parents and the vaccination of children just as there is the on-going debate about 'forced' fluoridation of drinking water. There is the new attention to what society eats and the dangers of obesity. What is the moral dimension to any decision to restrict medical treatment to a person whose life-style continues to contribute to obesity? All these examples pose the question about giving up what is bad for us and the so-called 'values' of our society.

It was inevitable that before long in the debate on rights and obligations that the word 'discrimination' should find its way into health care and health care provision vocabulary. Perhaps the clearest example of this stems from the question of smoking related diseases. It is suggested that those who smoke are placing an unnecessary financial burden on the rest of society because of the cost of treating 'smoking related' diseases. It is an interesting ethical discussion point as to whether the basis for anti-smoking policies should be based on this question of cost rather than on the effects of smoking on a person's life-style or on non-smokers such as in restaurants, pubs, or public transport.

In July 2000 the GMC Guidelines contained the following words :

"To treat justly or to ensure equity in the provision of treatment and care is at the centre of the NHS. It means that no one should be discriminated against because of their ability to pay, their social position, their health status, their race, religion, sex, lifestyle or their age. Indeed those whose needs are greatest .....even if their illnesses are to some extent self-inflicted, have the same rights as anyone else..."

So, are we to assume that current ethical thinking on health care must distinguish between another set of criteria : persuasion as opposed to prohibition and equality of treatment as opposed to any recognition of withholding medical care on grounds of life-style? In other words society introduces health warning notices on cigarette packets or alcoholic beverages, introduces prohibition of smoking in public places and, possibly, prohibits drinking of alcoholic beverages in certain areas on a criteria of encouraging people to stop smoking or excessive drinking on the one hand and thereby addressing excessive costing to health care by another means? In terms of ethics is this in fact an attempt by society to use the guise of better health, better life-style to tackle mounting health care costs? Or is the argument that we must improve our life styles per se?

Then secondly there is the role of the media.

Information on TV or in the press may produce a more informed and educated public which can 'own' the various issues that could one day affect their own lives or those of their loved-ones but it can also feed into fears and apprehensions if issues surrounding health care are dealt with in a sensationalist or irresponsible way. The media can also fuel a sense of mistrust between individuals and medical services. I submit that this trust is essential if a meaningful and effective participation in its public health service is to be achieved by society.

An illustration of the ethical difficulties surrounding public confidence and trust is provided by the recent case of Herceptin. Here we found how difficult it was to producing a rational public debate and thereby identifying any community value estimates. What were the elements to that case? First we learned that to treat one patient with Herceptin represented a cost in terms of services or treatments that would not be provided for others. Is there an ethical issue around the very public presentation by the media of those calling for the drug to treat their condition and the invisibility of those who would not receive other services? Did this enable those in authority to make objective decisions? How ethical is it to allow random forces like geographical location affect who gets treatment? Is it ethical to allow different health boards or authorities to make different decisions on provision of the drug? We were told that access became reduced to a 'post code lottery' in the typical sound-bite atmosphere to which that debate descended.

The Herceptin case highlights the confusing and often contradictory information that the media can generate. Am I alone in thinking that such a case leads to a deep mistrust of the NHS?

A third ingredient in this 'stormy sea' of ethical issues stems from the speed of medical progress.

The speed of current research is such that even legislation is unable to keep up with it. Lord Robert Winston in a recent conversation with me admitted that this was possibly the most significant of all health ethical considerations at present. In such a climate how can we reasonably expect medical researches to negotiate a path between important life-saving research and moral concerns. In fact can ethics even ask such researchers to concern themselves with such moral questions? Is that their role?

In this age of moral relativism as each of us has their own ethical concerns how can the medical profession take all of these concerns on board? How much can objective medical decision be swayed by individual perceptions of morality? As I understand it medical researchers are not just bound by their interest in saving lives, not just bound by their role in increasing the quality of life, they must also find ethical and acceptable ways of doing so, ways that will be acceptable to even those who may never receive such treatment. Of course we applaud ethics in medical research, but I also ask : can the medical profession be expected to take on board all such concerns? Is it acceptable to let people die so that the beliefs of the few can be satisfied? Is it right to refuse a particular treatment to a person who does not have a moral difficulty with it because of someone who may? What of the medical profession itself - what does ethics say about how they reconcile their own sense of morality with their work to heal? When I try as a student of ethics to understand from outside the intricacies of stem-cell research I am increasingly aware of the balance for researchers between effective ways of progressing their work and morally acceptable ways of doing so.

From such dilemmas and confusion in the ceaseless sea of ethics today, where do we turn for a new road map?

I have called this lecture 'A New Value Ethic?' I have put it in the form of a question and now I want to suggest in conclusion some interpretation of that approach. In fact my plea is for 'new ethics for all 'or' new ethics shared.'

As a society we have become in my life-time totally accustomed to receiving services. The demand not only in the arena of public health services but right across society, is for unlimited, unrestricted servicing. Such demands go hand in hand with consumerism. From the new cathedrals of the shopping malls to the availability of life-enhancing products, from the availability of necessary health and recreation-enhancing sources of advancement to accessibility of every conceivable service in DIY and ultimate self-enjoyment contemporary society knows no bounds to its demands for being serviced. What we are so slow to recognise in parallel is that that same society has to find ways of providing food for such an appetite. More than just ethics demands a balance between rights and responsibilities. Put plainly, society has the power to make the changes that would increase the effectiveness of the public health service. Human-kind is separated from other life forms by accessibility to that element we call responsibility - responsibility for our actions, responsibility for how we relate to others and how our actions affect others. So it is in the field of ethics that reciprocity stems from moral responsibility. The really mature society, the fulfilled individual, does not, should not, ignore the element of limitations to expectations just as there are limitations to personal freedoms. So a society that is ethically aware should not feel a burden is necessarily a bad thing. A willingness to sacrifice our own individual demands for the greater good implies that one day we may need that sacrifice from another. Such a society may be the ideal beyond our expectations, yet a society which can value such interdependence is one that has already discovered, perhaps without knowing it, a new value ethic - and one which makes some sense out of what is a restless sea of moral contradictions.

The Christian edict about 'who is my neighbour?' involves the answer - 'anyone who can be influenced by my actions.' Whatever may be our individual raison d'etre in what I call the ceaseless sea of ethics I believe it will be in the recognition and embrace of a new value ethic that health care will find its true place in this society - and become a principle of the common good which takes it above and beyond mere party politics.


Thank you for the privilege of sharing some reflections on these vital issues which in the end transcend both our disciplines. There are issues which concern the ultimate good of society. If the ceaseless sea of ethics is subject to weather forecasts then perhaps we all need to listen to those forecasts and as navigators be prepared to alter course if rocks are to be avoided ...