Category Archives: Equity

Related to the fairness of distribution of goods, opportunities, and processes.

Would you give knee surgery to the FAT MAN?

I do understand your plight, Mr Smith.  An arthritic knee can be extremely painful.  And you say it’s so bad you can’t even walk from the living room to the kitchen.  That’s actually very good news!  Yes, yes … awful … but terribly good news. If you can’t walk to the kitchen, you can’t eat. If you can’t eat you’ll lose weight.  And the faster you lose weight, the sooner we’ll schedule your knee surgery.

On 15 March 2017, Dr David Black, NHS England’s medical director for Yorkshire and the Humber, sent a letter of praise to the Rotherham Clinical Commissioning Group (RCCG).  The RCCG had decided to restrict the access to smokers and “dangerously overweight patients” of hip and knee surgery.  The letter was leaked, and it has triggered, according to the Guardian, “a storm of protest.”

The title of this blog is a play on David Edmond’s book, Would you kill the fat man, an exploration of moral philosophy and difficult choices about the valuation of human life. The RCCG’s decision intrigued me. It was essentially a decision about rationing a finite commodity — healthcare. In a world of plenty, rationing healthcare is a non-question.  In the real world, however, in a world of shrinking healthcare budgets and a squeezed NHS, resources must be allocated in a way that means some people will receive less healthcare or no healthcare.  Fairness requires that the rules of allocation are transparent and reasonable.

While you ponder, whether you would give knee surgery to the FAT MAN, I have a follow-up question.  Would you want to see a doctor who would deny you knee surgery because of some characteristic of yours unrelated to whether you would benefit from knee surgery?

I am sorry Mrs Smith, today we decided not to offer clinical services to women, people under 5’7″, or carpenters. We need to cut the costs of our clinical services, and by excluding those groups, we can save an absolute bundle.

I have heard it said of the doctor, academic and human rights advocate, Paul Farmer, that he would regularly re-allocate hospital resources from Boston to his very needy patients in Haiti.  He used to raid the drug stocks of a Boston hospital, stuff them in his suitcase and fly them back to his patients in Haiti.  I have no idea if the story is true or not. It does mark, however, one of the great traditions of medicine.  The role of a doctor is to advocate vigorously for the health (and often social) needs of the patient.  The patient actually in front of them.  The one in need.  Because, if your doctor will not advocate for your health needs, who will?  This is why all the great TV hospital dramas show a clash between the doctor and the hospital administrator.  Administrators ration.  Doctors treat.  The doctor goes all out to save little Jenny, against all odds.  The surly hospital administrator stands in front of the operating room, hand outstretched and declares (Pythonesque): “None shall pass.”

Under the current NHS system of clinical commissioning groups, there are family doctors who are simultaneously trying to make rational decisions about the allocation of limited resources to a population, and trying to be the best health advocates for the patient in front of them.  That screams conflict of interest. If you live in the catchment area of the RCCG and want my advice, check out which doctors are part of the RCCG.  If your doctor is one of them, change doctor immediately. Treating you, advocating for your health interests is what you need and should want.  Unfortunately, if she is part of the RCCG when she is treating you, you are not her principal concern.  Run(!) assuming of course that you don’t need knee surgery.

Should smokers and overweight people receive knee surgery?  Let’s start with smokers.  Why would you not want to treat a smoker?  It is difficult to come up with arguments that are not so outrageous that they are embarrassing to make. But I won’t let personal embarrassment get in the way of stating the top two silly arguments that came to mind:

  1. Smoking is a disgusting habit and anyone who smokes deserves all the pain they get?
  2. Smokers won’t live as long as non-smokers, so the investment in surgery to reduce pain and improve mobility in smokers will not have the net benefits to society as the same investment in non-smokers.

The arguments for restricting the surgery to people who are not overweight are similarly cringe-worthy.  There are also clinical reasons for prioritising the overweight.  The load on joints resulting from increased weight creates greater wear-and-tear and, the broader inflammatory processes that obesity triggers also seem to increase the risks of osteoarthritis — affecting hands as well as knees.  [See for example, here and here].

I can’t find the RCCG’s arguments for restricting access to knee surgery for smokers and people who are overweight, but prima facie it looks a lot like a variant of victim blaming.

Full disclosure.  I am all for the rational allocation of resources.  I think smoking is a disgusting habit. I am overweight and trying to do something about it.  I also think that the arguments for resource allocation need to be more explicit about the social values upon which they are often implicitly based.

Inequality of life expectancy between countries

A colleague of mine recently asked me if I knew of a citation for the narrowing in life expectancy between high-income countries (HICs) and low- and middle-income countries (LMICs).  I didn’t.  But the question did get me thinking.  Was there a narrowing between country-level life expectancy?  Probably … maybe … I didn’t know.

There are some very nice resources on life expectancy. I particularly liked Max Roser‘s post on the Our World in Data website.  None of the things I found, however, seemed to tackle the question of “the narrowing” in quite the way I wanted.  A longer search may have solved the problem, but it seemed just as easy to grab some data and have a look for myself.  While my colleague asked about a narrowing in the life expectancy gap according to the World Bank’s income classification (i.e., between HICs and LMICs), my interest was piqued by the broader question of the inequality in life expectancy between countries.

I decided to use the GapMinder data.  For a “quick and dirty” look it suited my purposes, it’s readily available, and the googlesheets R-package makes it trivial to access the data for re-purposing.  To simplify things, I calculated the deciles of life expectancy for the available countries in the gapminder data from 1870 to 2016.

I started with 1870 because in the years prior (from 1800) the gapminder data show nine largely unvarying parallel lines.  Around 1870 you can see that the life expectancy of the top (9th decile) improve rapidly, moving away from the pack of the lowest performing (90%) of countries.  The divergence continues until the beginning of World War I, when life expectancy in the 9th decile countries begin to decline as Europe started to implode. There is a sharp drop for life expectancies in all countries in 1918 marking the appearance of “Spanish Flu“.  After 1918 life expectancy in deciles 6-9 all start to improve, taking a dip for World War II; and then after World War II, life expectancy in all the deciles began to improve.  The overall pattern is one of narrow and low life expectancies in 1870.  Increasing disparity between the 1st and the 9th deciles, peaking around 1950, and then there is a gradual narrowing.

I find it quite difficult to make those kinds of visual comparisons, so I calculated a simple measure of inequality, the difference in years between the life expectancy of the 9th-decile countries and the life expectancy of the 1st-decile countries.

This 9th/1st decile gap (mis-named in the graph titles) in life expectancy is much, much clearer.  There is a relatively steady increase in the inequality, peaking around 1950.  There is then a steady decline in the inequality until the 1990s (when it increases again) and begins to decline again in 2000.  The narrowing inequality is, thus a relatively recent phenomena.  In 2016 the difference between the life expectancies in countries of the 9th- and the 1st-decile was 20.1 years.   In every year prior to 1909, the inequality was even lower.  Of course the life expectancies were also much lower.  In 2016 the life expectancies were 81.4 (9-th decile) and 61.3 (1st-decile), in 1909 they were 46.2 (9th-decile) and 26.0 (1st-decile).

The data extraction and plotting with the R-code is posted as a “gist” on GitHub.


The data are not without their problems, for one, they are derived from multiple sources (some better than others).  Another obvious problem is that a “country” is not static over time.  Countries come and go and their borders change. To ask then about the life expectancy of a country is not straightforward.  Imagine a country with significant regional disparities in life expectancy, and that country is then divided into two independent states along those same regional lines.  Simply by division, an inequality in life expectancy arises.  I did not try to discuss this, nor to weight the analysis by the population size of the country. On the gapminder site you can find details of the data sources.

Finally the difference between the 9th-decile and the 1st-decile is only one among many ways to measure and understand inequality.