The fundamental ethos of the NHS is egalitarian.


First published in April 2020.


In a world where the adjective “unprecedented” has become commonplace, the news of British Prime Minister Boris Johnson being admitted to the intensive care unit of St Thomas’ Hospital with COVID-19 seemed to take it to a new level.

There is little information in the public domain about Johnson’s medical condition, but this is clearly a very serious step. He will only have been transferred to intensive care because it is perceived that his condition is potentially life threatening and there is a possibility that he would need urgent medical attention, including the possible use of mechanical ventilation.

What would happen if that became necessary? Would Johnson’s treatment be any different from anyone else with the same condition? Would he receive special treatment because of his political position, because of his importance for the country? Would he be prioritised for a ventilator?

At any other time, this question might appear superfluous. The fundamental ethos of the NHS is egalitarian – patients are treated equally, based on clinical need.

The NHS constitution guarantees to treat patients equally regardless of gender, race, disability, age, sexual orientation, religion or belief. There is no mention of politicians, but it goes without saying that in the ordinary run of things, those in high office or low office – or no office at all – would and should be treated equally. That utter commitment to fair and equal treatment is one of the great virtues of the NHS.

But, of course, these are not ordinary times. Faced with overwhelming demands on health systems, there has been a recognition that it may simply not be possible to treat every patient equally, based purely on clinical need. An overarching principle for medical treatment during a pandemic is that, if required, it would be ethical to prioritise those patients who have the highest chance of surviving.

Could it be ethical to go beyond the chance of survival to include factors such as social utility? An influential international ethical framework, published recently in the New England Journal of Medicine, recommended that some critical COVID-19 treatments should go first to frontline healthcare workers and others who keep critical infrastructure working. They argued that this might be necessary to maintain a response to the pandemic. The authors, though, cautioned against favouring those who are wealthy or famous or politically powerful.

In the UK, new ethical guidance from the British Medical Association also suggests that if the situation is grave enough, it might be necessary to prioritise essential workers. However, that guidance was also very clear that if such a step were necessary, it should not be for doctors to decide: the government would need to indicate clearly what categories of workers were essential and should be favoured.

No such decision has been made to date.

Also, while the statistics are deeply concerning, at this stage, UK intensive care units are largely managing with the increased demand placed on their beds by the pandemic. The newly built field hospital, NHS Nightingale, was reported not to be needed as urgently as first thought. So while the situation is very serious, the worst-case scenario of needing to triage by non-medical factors does not apply.

The short answer then is that Johnson will not receive special access to treatment in intensive care. There is no suggestion that in the UK that patients would be treated differently because of their job position or title, or their importance to fighting the pandemic.

Different in other ways

But in another respects, Johnson’s treatment will not be identical to other patients. Those who work in intensive care are used to working in a highly stressful environment. The pandemic has raised stress to a new level, with massive clinical load, an ever-changing work environment and real worry about personal risk to self and colleagues. And now, those who work in the intensive care unit at St Thomas’ Hospital will have the additional strain of caring for the prime minister.

Much as they will try to treat him like any other patient, they will be acutely conscious of the weight of a nation’s anxious gaze. There are many small decisions and actions taken in the care of critically ill patients. Those decisions will feel momentous and fraught.

So if your thoughts are with the British prime minister at this time, please also spare a thought for the doctors, nurses and other healthcare staff who will be working to get him through this illness. They bear an unenviable burden and onerous responsibility.🔷


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[This piece was originally published in The Conversation and re-published in PMP Magazine on 7 April 2020, with the author’s consent. | The author writes in a personal capacity.]

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(Cover: Flickr/Number 10/Pippa Fowles. - Prime Minister Boris Johnson. / Licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.)



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