The Ethics of Private Payment for Health Care: The Example of Vaccination

30  July. This blog is an extended version of the post ‘Vaccines: All or Nothing’ (posted 29 July). 

A vaccine which would protect children from Meningitis B has been rejected by the Joint Committee on Vaccination and Immunisation (JCVI) as not cost effective, despite the fact the cost is not yet known.

The Department of Health’s director of immunization explained:

“This is a very difficult situation where we have a new vaccine against meningitis B but we lack important evidence. We need to know how well it will protect, how long it will protect and if it will stop the bacteria from spreading from person to person.

“We need to work with the scientific community and the manufacturer to find ways to resolve these uncertainties so that we can come to a clear answer.”

A call for more research is a standard answer to many dilemmas in healthcare, though perhaps one which is easy to ignore. As far as we know there are no current plans to ensure that this research takes place but the vaccine has already been found to be safe, and according to the BBC, “tests have suggested the vaccine is effective against 73% of the different strains of the disease”.

Resource allocation is an inevitable part of any health care system, and perhaps especially so in the NHS. Whilst we would like to provide all available treatments, prioritizing according to effectiveness and cost is necessary, though the exact method of calculating this (currently Quality Adjusted Life Years, or QALYs) is of course under intense debate and scrutiny.

In the meantime, children continue to suffer avoidable, lifelong disability due to infection with Meningitis B. I argue with Lach de Crespigny in a forthcoming paper on homebirth that actions (or failures to act) taken today which cause harm in the future are as wrong as if that harm were realized today. The plight of these children and adolescents should not be ignored.

Put simply, if you could prevent a child from getting brain damage, now or in the future, at little cost to you, you ought to perform that act.

One possible way forward would be to allow parents to pay for the vaccination of their child, at whatever price the company sets, just as holiday vaccinations can be provided by the NHS at a cost to the patient. Vaccinated children could be monitored and their data recorded. Not only would this generate the data that would establish how high up funding agendas this vaccine should be, but some individual children would be prevented from suffering this deadly and debilitating disease. To increase take up, the company would be under market pressure to keep the price as low as possible.

Of course, not everyone could afford the vaccine, and this would introduce some inequality into health care. But they would be more likely to receive the vaccine in the future if data shows that it is effective (and cost effective), and in any case are no worse off than under the current regime.

Another ethical point about paying for vaccination is that, even when it cannot be afforded by all, there are still benefits to those who can’t afford the vaccine. If enough people bought the vaccine , herd immunity might be induced and protect at least some of those who couldn’t afford it. Coverage might not be high enough to have a big impact, and we don’t really know whether or how well this vaccine induces herd immunity.

Parents are free to pay for safer cars, to pay extra for homes in safer areas, and to take various other expensive measures to ensure their child’s safety. Yet not everyone can afford these measures. Allowing the purchase of a vaccine would be another way which parents could increase their own child’s safety, if they had the means and decided to use them in this way.

It may be inevitable that we work in QALYs at a national level. But we should be free to choose how much to pay the small chance of avoiding a major harm at an individual level.

Increasingly the NHS, will have to give up the myth that it can provide universal health cover for all for all effective interventions. Increasingly, some interventions will be too expensive to offer within a public health system. But patients must know their options. There is evidence that doctors paternalistically (or for ideological reasons) fail to inform patients of all available options, such as high cost chemotherapy (1). This is an unethical failure to respect autonomy.

The best place to start in offer privately funded health care options is vaccination, since it promotes herd immunity and has beneficial effects for those who cannot afford vaccination.

References

  1. L. R. Mileshkin, P. Schofield, M. Jefford, E. Agalianos, M. Levine, A. Herschtal, J. Savulescu, J. Thomson,  J. R. Zalcberg, (2009). ‘To Tell or Not to Tell?: The Community Wants to Know about Expensive Anti-cancer Drugs as a Potential Treatment Option’Journal of Clinical Oncology.  Vol: 27 no. 34 pp 5830-5837   l
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4 Responses to The Ethics of Private Payment for Health Care: The Example of Vaccination

  • Jon Herington says:

    This all seems sensible, but what do you think of the following argument (which I’m not sure about, but seems at least worth addressing):

    Allowing private purchase assumes that cost-effectiveness tests for licensing are solely about how best to use resources from the Treasury, but they are also plausibly about protecting people in a particularly vulnerable epistemic state from making irrational cost/benefit analyses. Parents make healthcare decisions for their children under extreme pressure to give them the best care available, and thus operate in a context which promotes all the worst heuristics of decision-making – availability heuristics, inattention to likelihood etc. These heuristics are rife within patient decision-making even when its only their welfare which is at stake AND the evidence base for/against a treatment is very strong.

    We limit ‘consumer freedom’ all the time in markets where cognitive biases affect risk calculations: consider the heavy regulation of life insurance policies such that policies whose premiums manifestly outweigh the expected benefits can be outlawed. In much the same way, it could be claimed that its not a violation of autonomy at all to refuse to license a vaccine which (even on favourable assumptions of low cost and high prevalence) is not cost-effective.

  • Julian Savulescu says:

    Thanks Jon. I agree this is an argument worth considering. However, I think we are at risk of becoming overly paternalistic. Provide information and perhaps even set up default options that harness biases, but don’t restrict freedom. I think it is illiberal to claim that people are incompetent to make their own decision about something like vaccination. And it is up to individuals to decide what level of risk reduction is worth it. I have recently argued that when it comes to avoidable foreseeable harm to children, the threshold to intervene should be at even very low probability events. Seat belts only very slightly reduce the risk of injury to any single child but we still think that it is so important as to make them mandatory. People should at least have the chance to achieve small risk reductions at their own expense, even if these are not cost-effective at a community level.

    • Jon Herington says:

      In essence, I agree that we should allow the vaccine to be bought privately, provided it is safe and efficacious. I just think that the decision to restrict access has at least some reasons in favour of it (even if they are paternalistic), which wasn’t drawn out by your post. I think its worth investigating the degree to which parents are actually making autonomous decisions in their childs interests, and where there are serious deficits, it might be legitimate to require/restrict usage (as with seatbelts) rather than merely nudging or providing information.

      Just to clarify though, do you think its illiberal merely to restrict access based on cost-effectiveness? Or could this also apply to poorly efficacious drugs? Or even ones which had safety concerns? If “it is illiberal to claim that people are incompetent to make their own decision about vaccination” based upon cost-effectiveness, then isn’t it also illiberal to require drugs to meet a safety standard? (Obviously, its not illiberal to require them to go through a process which identifies whether or not they are risky – information being key to the end-user). An interesting argument along these lines was made by Jess Flanigan in the recent issue of PHE – worth reading if this is an ongoing project.

  • Mikaella P. Paulin says:

    I didn’t understand the lesson I hate this website.

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