Tuesday, February 19, 2008

Sandwiches, the NHS and Fairness

When I was about ten I was sent to a dreadful little prep school in Surrey called St Edmunds. It had lots of traditional rules whose origins were lost in the mists of time but no one had ever taken the trouble to write them down. So, new boys had to figure it all out by themselves. One of the pathetic regulations was that you were not allowed to make sandwiches at tea time. During the three years I endured at the school, the purpose of this rule was never disclosed, largely because there was no earthly reason for it. One day, I had the audacity to make a sandwich. My refusal to unmake it and worse to actually eat it meant the dispute escalated until I was standing in front of the headmaster. Eventually, as a ten year old alone at a boarding school, I was browbeaten into submission. In return, I have thought of the school and its staff with undisguised contempt ever since.

The only justification that the headmaster could muster for preventing me from eating my sandwich was that if he let me do it, then he would have to let everyone else do it as well. Fairness was used as a justification for stupidity. I expect many people are familiar with this excuse. It is one of the favourites used by bureaucrats as they seek to justify upholding their petty regulations in wildly inappropriate circumstances.

Sadly, the situation is sometimes more serious than a child’s right to make sandwiches. Recently, a cancer patient was told that she could not buy drugs with her own money without forfeiting the right to free treatment on the NHS. Disgustingly, Alan Johnson, the health secretary has supported the health authority's inhuman policy, apparently on the grounds of fairness. Now it is too late for poor Mrs Mills. If there is any justice Alan Johnson will be struck down by something that the NHS won’t treat with the latest drugs and be faced with the same choice between ‘fairness’ and an early death. This is not just a terrible parable about the perils of socialised medicine, but also shows the limits of using fairness as the final arbiter in morality.

The golden rule says, "Do unto others what you would have done to you." That means putting yourself in someone else's place and asking how you would feel if Alan Johnson banned you from buying a life-prolonging drug with your own money.

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David Taussig said...

James, I don't think you are being fair in your assessment of the situation. When you look at the original citation by Miller et al in the New England Journal of Medicine 2007 Dec 27th 357:2666-76 there is no significant difference between the standard chemo versus chemo plus avastin arms in terms of survival (Overall survival 26.7 vs 25.2 months P=0.16). There was a small advantage in terms of disease free survival but at a cost of increased toxicity.(http://content.nejm.org/cgi/content/abstract/357/26/2666).
Administration costs of drugs are significant per month. I'm not convinced this is a good use of NHS money.

James said...

David, I agree that the NHS should not have to pay for it. The scandal is that Mrs Mills was not allowed to do so with her own money. When you have terminal cancer a "small advantage" probably means a lot more than it does to us in the cold light of day.