Is this ethical?

The charges are best put by somebody who is not trying to survive them, so they are put that way here.

The second is the serious one, and it is worth being clear about why. Exclusion is a sin of omission: the hospital does not help people it was never going to help, which is true of almost every enterprise and is the ordinary condition of a market. It is uncomfortable and it is not unusual.

Extraction is different in kind. It is an act. The consultants exist, they are working, they are looking after people who have no alternative, and the plan is to pay them more to stop. That is not a failure to help. It is a transfer, from people with nothing to people with money, of a resource the country cannot replace at the rate it is losing it, and it was paid for by the public purse that trained them.

Nothing in the rest of this page softens that. The only thing that answers it is producing more clinicians than are taken, which is a thing that has not happened yet.

It is usually assumed that the exclusion question is purely ethical in this jurisdiction. That is wrong in one important respect, and the respect it is wrong in is the one that arrives at three in the morning.

Nigeria's National Health Act 2014 provides at section 20 that a health care provider, health worker or health establishment shall not refuse a person emergency medical treatment for any reason whatsoever. It is not a principle in a preamble. Refusal is an offence, it applies to private for profit establishments as squarely as to public ones, and for any reason whatsoever is about as unambiguous as statutory language gets.

So the commonest form of exclusion in this market, which is turning somebody away or holding them at a desk until a payment question is resolved, is not a grey area. It is very likely a crime, committed routinely, in a place where nobody enforces it.

Detaining a patient over an unpaid bill sits in the same territory without needing a health statute at all. Holding a person who is clinically fit to leave, against their will, because they owe money, is a deprivation of liberty, and the fact that it is common in parts of this market does not make it lawful. This study ruled it out several pages ago on values grounds. It is worth adding that it was probably never available as an option in the first place.

None of this is legal advice and the group will take its own. The point is narrower and it is about posture: a project that treats the emergency question as an ethical nicety to be balanced against commercial pressures has misread the position, because on that particular question the law has already decided and simply is not being enforced.

Outside the emergency, the legal position changes character completely, and the way it changes is instructive.

Nigeria's constitution does address health, and it does so among the fundamental objectives and directive principles of state policy, which are famously non justiciable. The state is directed to provide adequate medical facilities. Nobody can go to court and make it. A right that exists and cannot be enforced is a peculiar object: it settles the moral question and supplies no remedy.

Beyond that, on the ordinary operation of a private hospital, the law is largely silent. There is no obligation to treat people who cannot pay outside an emergency. There is no rule against hiring a consultant away from a public hospital, and there could hardly be one, since the alternative is indentured labour. There is nothing requiring anybody to count what their hiring does to the place they hire from.

So the two charges sit either side of a line. One of them runs into a criminal provision that nobody enforces. The other runs into nothing at all. And the most important thing to notice is that this tells you nothing whatever about which is worse.

Six arguments a project of this kind reaches for. Five of them fail and it is worth knowing which, because they will all be offered, usually sincerely.

The third deserves particular attention because it is the standard defence of private healthcare everywhere and it fails in this specific configuration. The usual argument is that private capacity decompresses the public system: paying patients leave the queue, so the queue is shorter for everybody else. That works where the private patients were in the queue.

Here they were not. The demand case for this hospital is built on capturing money that currently leaves the country, which means the patients it intends to serve are not waiting in a Nigerian public hospital. They are on aeroplanes. So there is no queue to decompress, no load decanted, and the only flow between the public system and this one runs the wrong way, in the form of its consultants.

That is not an incidental detail. It means the position here is worse than the ordinary private hospital case rather than equivalent to it, and a project that imports the standard defence without checking whether its premise holds has argued itself into a conclusion it is not entitled to.

Exclusion cannot be answered by argument, only by capacity given away, and capacity given away has a price that somebody pays. Here is the price.

If a share of capacity earns nothing, the patients who do pay carry the whole cost, and the price they see rises accordingly. The arithmetic is unforgiving and small: a tenth of the hospital provided free raises the price to everybody else by about a ninth.

Now put that number where it belongs, which is against the alternative the paying patient is actually weighing. That alternative is a flight, a hotel, two weeks away from work and a foreign hospital's private rate. An eleven per cent difference is not a rounding error but it is a long way inside the gap, which means a meaningful free care commitment is affordable in this market precisely because the competition is an international departure lounge.

That is an uncomfortable thing to write down, because it says the ethical commitment is cheap here for the same reason the business is attractive here. Both facts have the same cause. It does not make the commitment worth less, and it does remove the excuse that it cannot be afforded.

The arithmetic is also conservative, and the direction matters. It assumes a free case costs the same to treat as a paying one. In this market it will not: people who cannot pay arrive later and sicker, and their episodes will cost more. A group serious about this should size the commitment knowing that, rather than discovering it in year two and quietly reducing the share.

The group's own brand page sets a rule for what counts as a value: it has to say what it commits you to, what it costs, and how you would know it had been broken. Anything that cannot fill in all three is decoration.

So the answer to this page is not a paragraph of intent. It is six commitments in that form, and the third column is the one that matters, because a commitment with no breach condition is a sentiment and everybody involved knows it.

Two of them are absolutes with no acceptable rate. Emergency treatment regardless of means, and no detention for debt. Those are not targets to be managed toward, and the breach condition for both is a single instance.

The rest are measured, published and capable of being missed in public, which is the point. A free care share that is never reported is a press release. A clinician count baselined after opening measures a world the hospital has already changed. A crossover date that moves quietly has not been missed, it has been abandoned.

Which leaves the question underneath all of this, and it is the one worth ending on.

On the emergency, the law has decided and does not enforce. On everything else, the law has not decided at all. In both cases the practical position is identical: whether any of this happens depends entirely on what the organisation chooses, because nothing external will compel it.

The tempting inference is that where the law is silent, the matter is open. It is not, and the reason is not a moral flourish, it is a description of how this particular market works. The people harmed by both charges have no exit, because they were never customers, and no voice, because no channel was ever built for them. The stakeholder analysis on this site reaches that conclusion from a completely different direction. Where a harmed party has no instrument, the absence of a complaint is not evidence of anything, and the absence of a law is not permission. It is simply the condition under which nobody is watching.

That is precisely the circumstance in which a stated value is worth something rather than nothing. Compliance is what an organisation does when somebody is watching. A value is what it does when nobody is, and the only way to tell the difference from outside is whether the organisation published a breach condition in advance and then reported against it in a bad year.

So the honest answer to the question in the title is a conditional, and this study is not going to dress it up. As described at the start, with the outbidding and without the rest, it is not defensible: it takes from people who cannot object and gives to people who can pay, and calls the result a hospital. With the academy delivering, the counts published from an honest baseline, the emergency obligation treated as absolute and a real share of capacity given away at a real cost, it becomes defensible, and only then.

The difference between those two versions is not a matter of intention. Every one of them is a thing that either happens or does not, and every one of them can be checked by somebody who does not work here.

Three, and the first has no resolution available.

Everything on this page is a commitment this group makes, measures and reports on itself, concerning two groups of people who have no standing to hold it to any of them. External audit helps and it is not the same thing as accountability, because the auditor is also chosen and paid by the group. That is the real structural weakness of the whole position, it cannot be engineered away by a better commitment, and the only honest thing to do about it is to say so on the same page as the commitments rather than somewhere quieter.