[Paleopsych] J. Med. Ethics: The paradox of promoting choice in a collectivist system

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The paradox of promoting choice in a collectivist system
J Med Ethics 2005;31:187


Choice in a collectivist system

A Oliver1 and J G Evans2

1 LSE Health and Social Care, London School of Economics and Political
2 Green College, Oxford University

Correspondence to:
Dr A Oliver
LSE Health and Social Care, London School of Economics and Political
Science, Houghton Street, London WC2A 2AE, UK; a.j.oliver at lse.ac.uk
<mailto:a.j.oliver at lse.ac.uk>

Original version received 31 January 2005

Accepted for publication 8 February 2005


The notion of choice and its individualistic underpinnings is
fundamentally inconsistent with the collectivist NHS ethos

Abbreviations: GP, general practitioner; NHS, National Health Service

Keywords: choice; collectivism; individualism

In both the policy
<http://jme.bmjjournals.com/cgi/content/full/31/4/187#R1> and academic
<http://jme.bmjjournals.com/cgi/content/full/31/4/187#R2> 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. <http://jme.bmjjournals.com/cgi/content/full/31/4/187#R1>
Choice is often thought of as an intrinsically good thing; that is, that
people value choice in and of itself.
<http://jme.bmjjournals.com/cgi/content/full/31/4/187#R3> 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, <http://jme.bmjjournals.com/cgi/content/full/31/4/187#R5>
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

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.


1.	Department of Health. Choice of hospitals Guidance for PCTs, NHS
trusts and SHAs on offering patients choice of where they are treated.
London: Department of Health, 2003.
2.	Le Grand J . Motivation, agency, and public policy. Of knights
and knaves, pawns and queens. Oxford: Oxford University Press, 2003.
3.	Le Grand J . Choice, voice and the reform of public services.
LSE Health and Social Care Annual Lecture, London School of Economics
London, 9 Dec 2004.
4.	Beauchamp TL, Childress JF. Principles of biomedical ethics.
[5th ed] Oxford: Oxford University Press, 2001.
5.	Stevens S . Equity and choice: can the NHS offer both? A policy
perspective. In: Oliver A, ed. Equity in health and health care. London:
Nuffield Trust, 2003.

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