Article

Care

Comment

Economics

Ethics

2 December 2024

4 min read

NHS: How far do we go to feed the sacred system?

Balancing safeguards and economic expediencies after the assisted dying vote.

Callum Elwood

Callum is a pastor, based on a barge, in London's Docklands.

A patient eye view of six surgeons looking down.

National Cancer Institute via Unsplash.

“Die cheaply, protect the NHS” It sounds extreme, but it could become an unspoken policy. With MPs voting on 29th November to advance the assisted dying bill, Britain stands at a crossroads. Framed as a compassionate choice for the terminally ill, the bill raises profound ethical, societal, and economic concerns. In a nation where the NHS holds near-sacred status, this legislation risks leading us to a grim reality: lives sacrificed to sustain an overstretched healthcare system.

The passage of this legislation demands vigilance. To avoid human lives being sacrificed at the altar of an insatiable healthcare system, we must confront the potential dangers of assisted dying becoming an economic expedient cloaked in compassion.

The NHS has been part of British identity since its founding, offering universal care, free at the point of use. To be clear, this is a good thing—extraordinary levels of medical care are accessible to all, regardless of income. When my wife needed medical intervention while in labour, the NHS ensured we were not left with an unpayable bill.

Yet the NHS is more than a healthcare system; it has become a cultural icon. During the COVID-19 pandemic, it was elevated to near-religious status with weekly clapping, rainbow posters, and public declarations of loyalty. To criticise or call for reform often invites accusations of cruelty or inhumanity. A 2020 Ipsos MORI poll found that 74 per cent of Britons cited the NHS as a source of pride, more than any other institution.

However, the NHS’s demands continue to grow: waiting lists stretch ever longer, staff are overworked and underpaid, and funding is perpetually under strain. Like any idol, it demands sacrifices to sustain its appetite. In this context, the introduction of assisted dying legislation raises troubling questions about how far society might go to feed this sacred system.

Supporters of the Assisted Dying Bill argue that it will remain limited to exceptional cases, governed by strict safeguards. However, international evidence suggests otherwise.

In Belgium, the number of euthanasia cases rose by 267 per cent in less than a decade, with 2,656 cases in 2019 compared to 954 in 2010. Increasingly, these cases involve patients with psychiatric disorders or non-terminal illnesses. Canada has seen similar trends since legalising medical assistance in dying (MAiD) in 2016. By 2021, over 10,000 people had opted for MAiD, with eligibility expanding to include individuals with disabilities, mental health conditions, and even financial hardships.

The argument for safeguards is hardly reassuring, history shows they are often eroded over time. In Belgium and Canada, assisted dying has evolved from a last resort for the terminally ill to an option offered to the vulnerable and struggling. This raises an urgent question: how do we ensure Britain doesn’t follow this trajectory?

The NHS is under immense strain. With limited resources and growing demand, the temptation to frame assisted dying as an economic solution is real. While supporters present the legislation as compassionate, the potential for financial incentives to influence its application cannot be ignored.

Healthcare systems exist to uphold human dignity, not reduce life to an economic equation.

Consider a scenario: you are diagnosed with a complex, long-term, ultimately terminal illness. Option one involves intricate surgery, a lengthy hospital stay, and gruelling physiotherapy. The risks are high, the recovery tough, life not significantly lengthened, and the costs significant. Opting for this could be perceived as selfish—haven’t you heard how overstretched the NHS is? Don’t you care about real emergencies? Option two offers a "dignified" exit: assisted dying. It spares NHS resources and relieves your family of the burden of prolonged care. What starts as a choice may soon feel like an obligation for the vulnerable, elderly, or disabled—those who might already feel they are a financial or emotional burden.

This economic argument is unspoken but undeniable. When a system is stretched to breaking point, compassion risks becoming a convenient cloak for expedience.

The Assisted Dying Bill marks a critical moment for Britain. If passed into law, as now seems inevitable, it could redefine not only how we view healthcare but how we value life itself. To prevent this legislation from becoming a slippery slope, we must remain vigilant against the erosion of safeguards and the pressure of economic incentives.

At the same time, we must reassess our relationship with the NHS. It must no longer occupy a place of unquestioning reverence. Instead, we should view it with a balance of admiration and accountability. Reforming the NHS isn’t about dismantling it but ensuring it serves its true purpose: to protect life, not demand it.

Healthcare systems exist to uphold human dignity, not reduce life to an economic equation. If we continue to treat the NHS as sacred, the costs—moral, spiritual, and human—will become unbearable.

This moment requires courage: the courage to confront economic realities without compromising our moral foundations. As a society, we must advocate for policies that prioritise care, defend the vulnerable, and resist the reduction of life to an equation. Sacrifices will always be necessary in a healthcare system, but they must be sacrifices of commitment to care, not lives surrendered to convenience.

The path forward demands thoughtful reform and a collective reimagining of our values. If we value dignity and compassion, we must ensure that they remain more than rhetoric—they must be the principles that guide our every decision.

Explainer

Comment

Economics

29 October 2024

6 min read

How to tax ethically to avoid a two-tier society

From income tax to property and inheritance taxes, which is fairer?

Laurence Fletcher

Laurence Fletcher is a journalist at the Financial Times.

Sarah Agnew on Unsplash.

Few doubt that Chancellor Rachel Reeves will be putting up taxes when she presents her first Budget on October 30th.

The political narrative of recent months has very much been of an alleged fiscal “black hole” of £22bn - or is it £40bn? - that somehow needs to be filled.

While the size of the shortfall and the identity of those responsible are both hotly disputed, and despite a lack of detail from the Treasury about what it actually consists of, the questions now being asked are not whether taxes will rise but which ones and by how much.

Months of speculation have focused on employer National Insurance, capital gains tax and freezing income tax thresholds as areas that Reeves could look to for the additional revenue.

But beyond the immediate issue of raising enough revenue to make good any shortfall, lies a deeper, trickier question about the way in which taxes should be levied for the good of society. If a government is to force people and companies to hand over their money, then what is the most ethical way to do this? Who should pay and who shouldn’t? How can tax be used to reduce inequality and build a better society?

Answering such questions is, of course, far from straightforward, because there are plenty of other factors in play.

For instance, some taxes are surely levied because they are simpler to collect. Take income tax - an unpopular measure introduced in 1799, then abolished before being reintroduced as a supposed temporary measure. It could certainly be argued that taxing people’s income - their attempt to get on in life and improve their lot in life - is less “fair” than taxing wealth that has been accumulated by someone’s ancestors years ago. Working hard and earning income is often surely a way of breaking down class divisions. But income tax - contributing 28 per cent of UK government tax take in 2023-24, according to The Institute for Fiscal Studies - has the advantage that it is relatively difficult for the average worker at a UK company to avoid it. Ease of levying it is surely a driver.

Equally, some taxes that might seem “fairer” have deliberately not been levied because of the difficulty in collecting them, and/or because to try to do so could be counterproductive.

A wealth tax, for instance, would be “economically damaging”, according to one of the UK’s highest profile tax experts Dan Neidle.

Or take the politically contentious issue of non-doms, a colonial era tax break allowing rich foreigners to avoid UK tax on overseas income. It would be fairer, the argument goes, to tax them on the whole of their income. If they are going to be resident in the UK, then surely they should be taxed like a UK resident whose home is here?

Former Chancellor Jeremy Hunt abolished this regime earlier this year but left a number of concessions that the incoming Labour government pledged to abolish. But non-doms are tax-sensitive and highly mobile, and a number of jurisdictions compete to attract them. Many are entrepreneurs and wealth creators that many countries need. Reports have suggested a clampdown could raise no money or even cost money and could drive people away.

“Housing is being treated as a commodity. The problem is, it’s not; it’s not just an asset. It has utility value and a communal and quasi-spiritual value, enabling people to feel rooted.”

Paul Williams

So, what can be done to use tax in an ethical way? Paul Williams, research professor of marketplace theology and leadership at Regent College, Vancouver and chief executive of the Bible Society, takes a Biblical perspective that he believes offers some solutions.

He takes as his starting point a story from the gospel of Matthew, where Jesus is asked whether people should pay taxes to Caesar. The question is a trap - either Jesus gives his backing to taxation that is highly unpopular with the Jewish people, or he rejects the tax in an act of rebellion against the Romans.

Jesus replies that they should “pay to the Emperor what belongs to the Emperor, and pay to God what belongs to God.” We are to pay our taxes to those in authority, but we are also to honour God.

While Williams believes that too much emphasis is placed on the Budget and political parties’ promises to be able to fix everything, and that a more radical rethink of our economy is required, he also sees room for positive tweaks to the current system.

One key area is the property market, the manifestation of so much inequality in society, with some people owning multiple houses while others cannot afford to buy one.

Williams argues that the ready availability of debt finance has allowed those who already hold assets to easily acquire properties, turning real estate into an investable asset class to the detriment of many of the poorer in society.

“The reason there’s so many homeless people and empty houses is due to debt finance. It makes it easy for a relatively small proportion of the population to acquire a large percentage of the assets.

“The system has allowed a structure in which a small advantage in the beginning can lead to big, big differences over time.”

Williams highlights parts of Devon and Cornwall that have been, he says, “completely ruined” by wealthy people from elsewhere buying second homes, leaving property “out of reach of anyone who lives and works there”.

Nevertheless, he believes taxation can be used in this area to help level the playing field.

He proposes a “pretty punitive” marginal rate of tax on ownership of more than one home. (Stamp duty only partly does the job and is a blunt instrument also affecting people moving homes, thereby makes mobility expensive).

“You want to disincentivise the way the housing market is used for speculation,” he said.

“Housing is being treated as a commodity. The problem is, it’s not; it’s not just an asset. It has utility value and a communal and quasi-spiritual value, enabling people to feel rooted.”

Buy-to-lets, meanwhile, are better than having empty second or third homes, but “wouldn’t it be better if occupiers could buy that house?” he adds.

Meanwhile, research by the Financial Times recently found a huge wealth gap between the average millennial and the top 10 per cent of millennials, who are benefiting from family wealth to accumulate substantial housing assets.

So, would increasing the rate of inheritance tax - one of the most hated of taxes - and/or lowering the threshold also help reduce some of this inequality? After all, how is it fair that one child in the UK is born to inherit large property wealth while another is born to inherit little or nothing? Or, even worse, that second child will only ever be able to afford to be the tenant of the first, paying them rent for the rest of their lives?

Williams is not a fan of inheritance tax per se, arguing that it is “not part of the package” in a Biblical image of a flourishing economy.

But he adds an important caveat: “the playing field is not level.

“There might be circumstances to impose a one-off tax on the very wealthy… if you want a transition to a more equitable society.”

Such steps are not easy to take. It is, he admits, probably “career suicide” for a politician to adopt such views. But if we are to take steps towards a fairer way of life, and avoid a two-tier society in decades to come, then maybe the conversation needs to shift this way. Perhaps the Budget could be the time to start.