Paying for better health: Should patients be able to pay for expensive cancer drugs?

In the last month there have been a number of cases of patients with terminal cancer appealing for access to novel drugs that are not currently funded under the NHS. In Scotland yesterday a man with terminal bowel cancer succeeded in his battle to get NHS funding for a new and expensive drug cetuximab. This follows the recent publicity over two patients with breast cancer who have been fighting to be allowed to pay privately for another new drug bevacizumab.

These drugs are genetically engineered antibodies developed by a US biotech company to target growth factors commonly found in tumour cells. The drugs have been shown to improve survival of patients with some cancers, but evidence is lacking in other types of cancer.

This sort of dilemma is not unique to the UK. There is similar debate about access to bevacizumab in Canada and Australia. Some of the debate is about the science, and whether or not the drugs have been conclusively proven to be of benefit. However there are also ethical questions about the rationing of expensive treatments in public health care systems. It is generally accepted that there are finite resources available for healthcare, and that not all treatments can be afforded. But if public funding isn’t available for health treatment should patients be able to pay privately to access them?

The main concern about patients paying for medicines is that it
conflicts with egalitarian ideals of healthcare. While some cancer
patients may be able to afford the expensive new drugs, others will
not. This raises the prospect of inequality in health care on the basis
of wealth. Concerns about justice give rise to claims that this would
be “unfair” for patients unable to afford the new drugs. The health
department in the UK claims that allowing patients to pay for drugs
privately would give rise to a “two-tier” system.

The official response to patients attempting to pay privately for drugs
such as bevacizumab has been to threaten to withhold funding from those
patients for the rest of their NHS treatment. This means that patients
can pay privately for all of their healthcare, or none of it – but
cannot mix private and public health care.

However such an approach is hard to justify. Since patients can still
pay privately for health care a two-tier healthcare system will still
result, with some patients able to afford the new drugs, while others
cannot. The only difference is that patients wishing to access the
drugs are financially penalised by being denied NHS treatment (to which
they have contributed as tax-payers).

Is a two-tier healthcare system a bad thing? On strong versions of
egalitarianism, there should be no difference in access to health-care
on the basis of wealth. However in a state with finite health
resources, the only way to achieve this is by restricting the liberty
of wealthier citizens to buy additional health care. Alternatively
egalitarianism might stipulate that should be no difference in access
to a basic standard of health-care. On this basis it does not matter if
there are different tiers of health-care as long as the minimum level
(to which all have access) is sufficient.

The price of strong egalitarianism in health-care is high. To uphold it
we would need to prevent wealthy patients accessing any private
healthcare in the UK (or overseas). More measured versions would allow
patients to buy drugs like bevacizumab that cannot be afforded in the
public system. However penalising them for doing so makes no sense at
all.

Further reading

Threat to halt NHS care for cancer patient – Times 16/12/2007

Fears over cancer drug costs – BBC 14/5/2007

Should NHS patients be able to contribute money to their care? – article from BMJ 2002