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Comment by emteycz | Hacker News Reader

But sometimes NHS won't pay and will forbid you from paying yourself: https://edition.cnn.com/2018/04/25/health/alfie-evans-appeal...

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NHS won't forbid you from paying, such an order would come from the Courts. It's an exceptional case that a family would have this kind of rule imposed on them, but Courts will consider the patient's best interests before the family's.

Yes, the publicity around the case overshadowed that this wasn't a case about health resources, but about what was right and best for the patient.

Please do not spread misinformation – this was not a case about the health service paying for treatments. It was specifically about whether or not life support should continue to be provided, or whether doing so was inhumane.

NHS has nothing to do with electing to pay for your own treatment - people do it sometimes for elective stuff.

That was a court of law which ruled in that case (and then again for multiple appeals processes), the NHS has no such power.

This is exactly right. Where the NHS won't pay you're free to go private. This case, and that of Charlie Gard, were quite different. The dispute was a welfare one: whether the best interests of the child (Alfie) were to be allowed to die, or to undergo experimental treatment where it was pretty clear it would have no benefit. There's quite a good explainer (which sets out why it was both complicated and emotional) in Vox[0].

But it can't be stressed enough that this was about who makes the decisions, not about who pays for care. The money was there to pay for the alternative treatment (fundraised, in this case).

The question was whether the parents have the right to make the final decision, or the courts. And English law is very clear that in the end the High Court has the power to make care decisions in place of the parents when it believes it is acting in the best interests of the child. And that extends to withdrawing care and allowing the child to die.

You may not want judges to have that degree of power. That, honestly, they exercise it extremely carefully may not be a comfort. You may think that the parents' view should always control. That's fine. But that has nothing to do with the NHS and its funding system. The same issues would arise even if the child was in a private hospital and the parents wanted to pursue futile treatment against the advice of the medical staff.

https://www.vox.com/policy-and-politics/2018/4/27/17286168/a...

>But that has nothing to do with the NHS and its funding system.

It does. It is much more legitimized to delegate these kinds of decisions to the state when the state is paying for the health care. In other words, the state paying for care is a pre-requisite to the state having the ability to make these kinds of extreme/overruling decisions about care. Otherwise people wouldn't tolerate it. The state paying for care is a power dynamic.

Consider the opposite, of a state that doesn't pay for any care, telling Alfie Evans parents that they have to take him off of life support, and tell me that you think the social reaction would be the same and people would just accept it. They wouldn't, and that shows you how much the issues are linked. Again, it's a power dynamic that increases legitimacy.

There are several cases in the US where courts override parents wishes, while it's true US courts tend to give more rights to the parent than the courts in determining what's best for the child - at least for middle class parents - in Custody of a Minor (and other cases), the court held that family autonomy is not absolute.

For your "opposite" case, where a court could order removal of a baby from life support, there have been several cases in America

https://www.chron.com/news/houston-texas/article/Baby-dies-a...

"Sun's death marks the first time a U.S. judge has allowed a hospital to discontinue an infant's life-sustaining care against a parent's wishes, according to bioethical experts. A similar case involving a 68-year-old man in a vegetative state at another Houston hospital is before a court now."

I'm not arguing that it has never/will never happen in America. I was trying to be careful with my wording, eg "more legitimized." I think that a place where healthcare is government funded is more likely to accept decisions that other places consider overreaching by the state.

My underlying point is the power dynamic between a government and its people, and the argument that a government "providing" more things increases that dynamic in the favor of the government. This makes any decisions related to that dynamic more legitimized.

Do you have any evidence to back up your claim?

The US government provides 27% of things in the US (budget vs GDP), about the same as South Korea and Switzerland, more than Ireland (23%), less than New Zealand (32%), UK (33%), Spain (34%), but not by an extreme amount.

>The US government provides 27% of things in the US (budget vs GDP)

This is silly. Budget vs GDP is not how you measure how much a government provides. You're not controlling for waste.

The state's parens patriae jurisdiction (where originally the King, as 'father of the country' and latterly the courts can take decisions on behalf of those who cannot take care of themselves) goes back centuries - far longer than the NHS does.

And for what it's worth, these cases are basically never discussed even outside the courts in the UK on the basis of 'can we afford it?', but rather 'is it the right thing to do?'. There are financial constraints on the NHS, particularly on the provision of care for chronic conditions and expensive new drugs with positive but marginal utility, but these kinds of 'right to life' cases are not where it bites.

I don't know enough about UK history, but was the king also expected to provide for the people? In that case, I would argue that my power dynamic argument still applies. In other words, a king that provides is seen as having more legitimacy to the people over one that doesn't, and so their decisions are more willingly accepted.

Arguably they were expected to provide security against external threats, but otherwise no: any social services were the responsibility of the parish in the early history of England. National poor relief laws date to the late 16th Century, but the responsibility falls locally, not from the King. This doesn't really begin to change until the early 20th Century, with the national provision of old-age pensions. Most of the sense of the national government as directly providing for the people comes post-World War 2, not before.

That was not a dispute about payment.

That’s an obscene example of government interference with family and human life. This is an extreme example but there are many more misery inducing circumstances that are by products of a single payer system wedded to government. One of the most pervasive is a general rationing of care with long delays before procedures or even basic diagnostic tests but there are others like having to be assigned a doctor or having little to no choice of hospitals or clinics. The modern world needs a system that provides options for everyone and there must be a way to structure healthcare so that those who can’t afford it still receive it while those who can are able to buy the service they want. Everyone should receive the best care but you have to allow the market to find the best solutions do everyone can benefit from them. It’s just like taxing the rich if you want to look at it that way, they shell out gobs of money to create a demand for top notch doctors and facilities and the government then legislates that those resources must also provide care for everyone in exchange for access to something only the government can provide like tax breaks etc.

'Family' and 'human life' does not over-ride all else, which is obvious in cases of abuse or neglect. It's more complicated when medical experts and parents disagree on what is best for the child. What you understand as the 'best care' may not be the same as what an expert in that area may understand as 'best care'.

'Everyone should receive the best care' - so how do you suggest this is best done?

This has nothing to do with the specific of the healthcare system, but about child protection measures.

The NHS had no power to stop them, and did not. The courts did because the parents were taking actions that were not supported by medical evidence.

As for the rest of what you're saying, it is also unsupported both by evidence, and by the fact that the UK does have a free market for medical treatment, one that is far cheaper than the US, and for health insurance, that is far cheaper than the US. One might argue it would be paying twice, but the NHS costs about the same per capita as Medicare and Medicaid combined, so Americans pay twice. But the NHS offers universal cover for that price.

UK health insurance is in general cheaper than in the US because there's no demand for comprehensive cover - almost all the cover is "top up" and "queue jumping" type cover that assumes people go to the NHS first and get referred private if they need something that can't be offered quickly enough by the NHS or that isn't covered.

Yet despite the low cost, only about 10% of people in the UK feel a need to obtain private health insurance.

The free market has spoken - for most it does not offer compelling alternatives to the NHS.

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