Book Review

Who Should We Treat? Law, patients, and resources in the NHS

N Engl J Med 1996; 335:756-757September 5, 1996

Article

Who Should We Treat? Law, patients, and resources in the NHS
By Christopher Newdick. 323 pp. New York, Oxford University Press, 1995. $74. ISBN: 0-19-825924-7

Every country's health system is in crisis. In the absence of clear “best practices,” cynics might remark that reform usually consists of replacing one set of problems with a new set, and then beginning a new process of change. International comparisons have therefore become a popular pastime — both in the illusory quest for the right path and for the consolation of knowing that others have problems too. In the past, many Americans could look to Britain's National Health Service (NHS) in search of the “evils of socialized medicine”; scholars were, like the police chief in Casablanca, “shocked, shocked” to see that scarce resources were rationed there. Now that Britain has introduced competition (in the form of the purchaser–provider split) and the United States has recognized that rationing is inevitable whenever one must allocate scarce resources (most explicitly in the Oregon experiment), the lessons learned from abroad can be more subtle. This ambitious effort by Christopher Newdick, a barrister and a Reader in Health Law at the University of Reading, purports to present a legal approach to ethical questions of resource allocation in the National Health Service but is of broader interest.

The book has a remarkably wide scope. The table of contents is daunting, including a 10-page index of cases cited (not only from the United Kingdom but also from the United States, Canada, and Australia, with one apiece from New Zealand and Malaysia), followed by a 14-page table of legislation, 3 pages of “guidance notes” (which appear to be references to government documents), and a listing of abbreviations. One is thus unprepared for the lively writing style. The book is replete with wise statements, always made with the utmost confidence and extensively footnoted. I would feel like a curmudgeon if I noted omitted references (e.g., to the extensive international comparisons done by the Organization for Economic Cooperation and Development) or unstated alternative viewpoints, especially since I tended to agree with many of Newdick's conclusions.

The first chapter gives a general overview of the pressures on the National Health Service but detours into an interesting (albeit opinionated) discussion of the ethical aspects of such economic approaches to assigning value to health outcomes as the quality-adjusted life year. Chapter 2 gives a description of the National Health Service and its move toward managed competition, with an excellent discussion of the impact of these contractual arrangements on costs and care.

The middle of the book is both more lawyerly and more specific to the United Kingdom, addressing quality assurance and accountability by considering how standards can be regulated through the common law (chapter 3) and by statute (chapter 4), the implications of the rise of health-service managers (chapter 5), the accountability of various parties within the National Health Service (chapter 6), and the procedure for complaints (chapter 7). The book concludes by discussing the implications of these findings on “ethics in the new National Health Service” and the implications for clinical freedom, but it lacks a pithy wrap-up of its themes.

Newdick recognizes the conflicts inherent in trying to balance costs and quality, but in the final analysis comes down on the side of patients, ethicists, and malpractice lawyers, as opposed to managers and economists (with providers caught in the middle). All sides could profit from reading this book, which helps remind us of some of the practical perils of too much attention to the bottom line.

Raisa B. Deber, Ph.D.
University of Toronto Faculty of Medicine, Toronto, ON M5S 1A8, Canada