THE DECISION of the Ipswich Primary Care Trust to refuse hip and knee replacements to the fat until they have lost weight is not without medical justification. The fat have many more complications after surgery and worse outcomes than the lean and svelte. If surgical time and facilities are limited, is it not sensible to offer surgery first to those who will benefit most from it? This is especially so where the condition to be corrected, as in hip and knee replacements, is itself caused or exacerbated by obesity.

Yet in these days when few official pronouncements mean what they appear to mean, and indeed often mean the very opposite (for example, one hospital trust of my acquaintance recently announced that it was “saving” 30 nursing jobs, by which it meant that it was sacking 30 nurses), it is only natural that we should search for other reasons for the trust’s decision.

The trust admitted that its main motive was financial, because it had overspent its budget by £47.9 million, but cutting back on medical services is only marginally economic. To save substantial sums, such services have to be cut disproportionately. What the trust really meant was that it needed to save £47.9 million without cutting back on administrative costs. Indeed, it stands to reason that the more financial chaos there is, the more management is needed to sort it out.

In the first place, the trust’s decision could be used to help to keep waiting lists down, and we should not forget that managers are rewarded and promoted by meeting arbitrary but binding targets. A fat man who has so far failed to lose weight could be conveniently omitted from the waiting list as being ineligible for surgery.

As the population grows fatter, this could be a powerful means of reducing waiting lists: far more effective, statistically, economically and bureaucratically, than training more surgeons, expanding hospitals, spending more money on patients and so on. Ipswich has shown us the way forward, if not to a healthier population, at least to a politically more presentable health service by means of creative statistics. Spin comes to medicine.

The second thing that the decision illustrates is that, in modern society, risk can no longer be accepted and borne by the person who is at risk, but rather by the people who have been made responsible for his welfare. A patient under the new Ipswich dispensation cannot simply accept on his own behalf the additional risk consequent upon his obesity. He cannot choose between a greater risk now, and a lesser risk later if he should lose some weight; the decision is simply taken out of his hands. This assorts ill with the principle of patient autonomy, which has become the touchstone of modern medical ethics.

Thirdly, I suspect — though I cannot prove — that there is a degree of moral disapprobation of the fat behind the Trust’s decision. It look likes a decision made with pursed lips, and we should never lose sight of the satisfaction browbeaten officials derive from denying people what they need, justified by their moral failings. After all, obesity is self-inflicted: it indicates a lack of self-control. How else is one to explain the epidemic of obesity afflicting Britain? The fat are guilty of sloth and gluttony, and deserve to wait in pain for their operations.

I agree that obesity is the result of a loss of self-control. Indeed, loss of self-control might be said to be the defining social (or anti-social) characteristic of our age: public drunkenness, excessive gambling, promiscuity and common-or-garden rudeness are all examples of our collective loss of self-control.

Unfortunately, we have at the same time the cruel and sentimental notion that only unsullied victims are worthy of sympathy and assistance, and that the world is neatly divided into victims and perpetrators. A thin man with crippling osteoarthritis is a victim; he has done nothing to bring his condition on himself (except, perhaps, play sport in his youth, which, as we know, is intrinsically admirable and to be encouraged). A fat man with crippling osteoarthritis, on the other hand, is the author of his own misfortune, and is thus not eligible for our sympathy or concern. As Marie Antoinette might say if she came back today as a health service manager, let them eat dust.

The Christian belief, that we are all sinners capable of redemption, though not in this world, seems to me vastly more sophisticated in its understanding of the human predicament, than the secularised Manichean view that divides people into victims and perpetrators. I say this as a non-believer.

Very few people are morally consistent, however. If fertility clinics took the same line as the Ipswich trust, and refused in vitro fertilisation to unmarried women on the ground that the children of unmarried women were more likely to suffer from an entire range of social pathologies, vastly worse for society than the bad outcome of a hip replacement, even those who would deny operations to the fat on the grounds of their contributory sloth and gluttony would be appalled.

This suggests that there is a rough law of conservation of moral outrage in society: the quantity is always more or less the same, but it attaches to different things. For example, smoking cannabis no longer outrages us, but smoking tobacco does.

The conscious rationing of healthcare by administrators will allow them to smuggle moral judgments and psychological gratifications into their decisions in the guise of procuring best value for money. And obtaining best value for money (supposing that it is possible with anything like scientific exactitude, which is in many cases often doubtful) is itself a moral value whose truth and validity is treated as self-evident. As someone who is entering a stage of life in which its “value” is declining daily, I am not sure I agree.





The author is a recently retired doctor

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