Medical science continues to push at the boundaries of life and death with new drugs and technologies that can extend life or improve health. But these advances come at a cost. And that inevitably raises difficult questions about whether public health systems should pay for such treatments – and, if so, how much. For example, should the NHS fund the new breast cancer drug Kadycla which comes with a £90,000 price tag per patient?
Some countries make these difficult decisions by looking at the cost-effectiveness of new treatments. How much does the new treatment cost and how effective is it compared with existing treatments? Treatments may help patients live longer, or they may improve a patient’s quality of life (or both). Kadycla appears to extend life by about six months.
One mathematical way of combining these elements uses the concept of a Quality-Adjusted Life Year saved, or QALY. As an example, a treatment that extends life for one year but at a “quality” level of half normal it said to save 0.5 QALY. When treatments are assessed this way, health systems can then use a threshold to work out a maximum cost that is affordable. The National Institute for Health and Care Excellence (NICE) uses a threshold of £20,000-£30,000 for each Quality-Adjusted Life Year saved (QALY). This would mean (assuming full quality of life), that the NHS would be prepared to pay £10,000-15,000 for a course of Kadycla.
By Dominic Wilkinson @Neonatalethics
At the bedside of a critically ill infant at 5am this morning I was tempted to tweet the latest meme, adding my voice to a chorus of NHS clinicians over the weekend. Last week, in a speech to the King’s fund, Health Minister Jeremy Hunt launched a drive towards 7 day NHS. In particular, he focused on consultant contracts, proposing that newly qualified hospital doctors will be required to work weekends as a condition of employment.
I highly recommend Leif Wenar’s essay “Poverty Is No Pond” – especially to those not yet familiar with, but interested in, the empirical complexities involved in giving to overseas poverty-fighting charities. Wenar’s main aim in his essay is to criticize Peter Singer’s 2009 book The Life You Can Save for (i) being overly optimistic about the quality of information available on the effects of giving to various charities, and (ii) failing to emphasize that every charitable donation also comes with some risk of harming people living in extreme poverty. I’ll only briefly address (i), and then turn to and focus primarily on (ii).
By Dominic Wilkinson (@Neonatal Ethics)
Late last month, a paper in the US journal Obstetrics and Gynecology reported the extraordinary case of Abigail Beutler. Abigail is now 14 months old. She was born without kidneys, a condition sometimes called ‘Potter’s syndrome’. Potter’s syndrome is normally universally fatal in the newborn period, because without kidneys the fetus does not produce urine and has little or no fluid around them. Without any fluid around the fetus, their lungs do not develop.
Abigail is the first baby to ever survive with this condition. Doctors infused artificial fluid into the uterus around her (amnioinfusion) on five occasions during the pregnancy. This seemed to allow her lungs to grow. Although she was born 3 months prematurely, she had only minor breathing problems at birth. She has received kidney dialysis since soon after birth, was discharged home after 19 weeks and is now reportedly being considered for a kidney transplant. Continue reading
by Dominic Wilkinson (@NeonatalEthics)
Lord Falconer’s assisted dying bill is being debated today in the House of Lords. In the past week or two there has discussion in the media of many of the familiar arguments for and against such a proposal. As Roger Crisp noted in yesterday’s post, there have been relatively few new arguments. Supporters of the bill refer to compassion for the terminally ill, the difficulty of adequately relieving suffering, and patients’ right to make fundamental choices about the last stage of their lives. Opponents of the bill express their compassion for the terminally ill and those with disabilities, fear about coercion, and the omnipresent slippery slope.
One concern that has been raised about the assisted dying bill is the fear of abuse in the setting of an overstretched public health system. For example, Penny Pepper, writing in the Guardian notes that “Cuts to social care are monstrous…How would the enactment of the Falconer bill work if brought to our harassed NHS?”
At some point, most people will have questioned the necessity of the existence of mosquitoes. In the UK at least, the things that might prompt us into such reflection are probably trivial; in my own case, the mild irritation of an itchy and unsightly swelling caused by a mosquito bite will normally lead me to rue the existence of these blood-sucking pests. Elsewhere though, mosquitoes lead to problems that are far from trivial; in Africa the Anopheles gambiae mosquito is the major vector of malaria, a disease that is estimated to kill more than 1 million people each year, most of whom are African children. Continue reading
There are approximately 150,000 human deaths each day around the world. Most of those deaths pass without much notice, yet in the last ten days one death has received enormous, perhaps unprecedented, attention. The death and funeral of Nelson Mandela have been accompanied by countless pages of newsprint and hours of radio and television coverage. Much has been made of what was, by any account, an extraordinary life. There has been less attention, though, on Mandela’s last months and days. One uncomfortable question has not been asked. Was it ethical for this exceptional individual to receive treatment that would be denied to almost everyone else? Continue reading