24 August 2010
The price of life?
The National Institute for Health and Clinical Excellence (NICE), charged to determine whether drugs are good value for money for the NHS, has decided that the anti-bowel cancer drug avastin, also known as bevacizumab, is not worth the average cost of £21,000 per patient for an average extension of life expectancy of only six weeks. It is used only in advanced cases.
The campaign group Bowel Cancer UK has protested against the decision, arguing that the 6,500 sufferers each year have a right to any medication that might extend their lives.
However, I have to agree with NICE: £21,000 for six weeks extra life is not good value for money for the taxpayer. On the figures quoted it appears the extra cost to the taxpayer would be £136m per year.
I certainly would not expect that sort of public expenditure to keep me alive for an extra six weeks and if ever I am in the unfortunate position of suffering from bowel cancer I will refuse the drug if offered on the NHS. I or my relatives might have special reasons to want those extra weeks of life for me and might be prepared to find the money by some means but I would not expect the taxpayer to stomp it up.
The decision is riddled with questions of relativity. Suppose the equation were £100,000 for just one extra day of life? How many would argue for it then? Issues of quality of life are also relevant and no doubt NICE takes those into account too in arriving at its decisions.
This is not the sort of decision that can be taken on the basis of a principle – it has to be on the basis of common sense.
I believe there are a number of drugs that have not made it on to NICE’s list for the same reason. If all were approved on principle then NHS costs would rise significantly and drugs companies would be given licence to manufacture all sorts of exotic and expensive drugs in the sure knowledge that the NHS would have to cover the cost. Their profits would be guaranteed on the back of a rising tax bill for working people.
You are entitled to ask where I would draw the line and for the sake of argument I propose that drugs should only be approved if for a cost equivalent to the national average annual wage (circa £26,000) an extension of life of 12 months could be anticipated. No, there’s no connection, it’s just an intuitive guide to reasonableness.
Anyone contributing is, I think, obliged to state where they would draw the line.
There are two people for whom I would definitely NOT pay the £21000: myself and my husband.
For all others, like a good Humanist, I would consider their cases on their individual merits. Maybe the NHS should allow clinicians to do the same.
Supporters of the NHS should be the keenest to see that it spends money wisely and gets good value for money. This is not a 'moral' or human rights question, it is a simple economic one that shades into politics.
The problem with saying that decisions should be left to clinicians on the basis of individual merit is that it places too much responsibility on them and puts them in the firing line. Some would say it puts them in the position of God, but obviously, on an atheist blog, you would not expect to see that argument!
What would you do if you were a clinician who had discretion? You would give the drug to everybody, of course, to avoid all the challenges that would follow even the most sensible of discriminations. Then it would be impossible to control the budget and drugs companies would be encouraged to manufacture all sorts of exotic drugs at exorbitant prices that they knew would find a ready market in the NHS.
Either the mildly rough justice of a body like NICE, deciding which drugs provide reasonable value for public NHS money, or some other form of central rationing - eg. nobody over 50 to be given the drug, or smokers, or clinically obese people, etc. etc., could take the pressure of both the budgets and the clinicians.
It seems to me that the question as posed - what price/value can you place on life, to paraphrase - is the wrong question. Sure, if an intervention, in this case a drug, actually cost £21000 to manufacture and distribute then I think this discussion would be worth having.
But it doesn't cost that much does it? It only costs that much because that's what the pharmaceutical company decides to charge for it. And they can pretty much charge what they like.
For me the real question is should we allow that? You are right that we have to be good stewards of public money. But can it be right to deny interventions to people because the pharmaceutical business wants to maintain it's status quo as "the most profitable industry in the US"?
Similarly, we could as a nation put an end to almost all road traffic accident deaths by banning motor vehicles. Why don't we do it? Because the cost in terms of lost economic activity and mass poverty that would follow would be unbearable.
So, there is currently a frequent and well known practice of making decisions about human welfare based on cost.
Just assume for a moment that we live in a non-capitalist democratic world where we are constantly faced with decisions about the application of scarce resources to meeting human needs. Let us assume, further, that there is a rare fatal physiological disorder that the state medical researchers believe can be delayed in its fatal effect by a period of one week if a new machine is built. The machine will cost £10m to build. It will extend the lives of 5 people each year by one week. The machine's working life is estimated at 5 years. So, each extra week of life for the five victims annually will cost £400,000 of taxpayers' money.
Is it worth it?
It's a simple enough question.