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Cold and Calculating NICE

Yesterday’s Daily Mail online contains an opinion piece bemoaning the decision by NICE – the UK body responsible for rationing healthcare resources – to decline funding for four new treatments for Kidney Cancer. The Mail complains:

…what does NICE offer by way of explanation? A cold, calculating statement that, while the drugs work for many of those with advanced kidney cancer, they are not ‘cost-effective’.

What a clinical way to assess whether a person should be afforded precious extra months and years of life, or consigned to a ‘death sentence’.

I don’t want to defend NICE’s decision in this particular case, but the Mail’s attack on NICE’s "clinical" decision-making process is clearly unjustified.

In making decisions about what treatments to fund, NICE inevitably places an value on human life. This is unavoidable. The value can either be made explicit, or can be left implicit. But either way, decisions not to fund certain treatments will imply that the benefits that can be had from those treatments – in terms of increased quality and quantity of life – do not match the costs of the drug, which will generally take the form of depriving patients elsewhere in the healthcare system of other treatments. 

The Mail seems to accept that such rationing decisions are necessary, admitting that "The Health Service does not have infinite resources, and, sadly, will not be able to fund every expensive new treatment." Rather, its main general concern seems to be about the explicit nature of NICE’s decision-making process, which is based in part on determining the number of Quality Adjusted Life Years that a treatment can be expected to provide and balancing this benefit against the treatment’s economic cost.

But what alternative is there? Prior to the existence of funding bodies like NICE, healthcare rationing decisions were largely determined by the political clout of competing drug companies and the various medical specialties. But surely that wasn’t a better way of making decisions. Another alternative would be for NICE to make their decisions on the basis of a emotional judgements. This is perhaps how we would expect one another to think about matters of life and death. We would probably regard an individual person who was, in his everyday life, as prepared as NICE to make explicit judgements about the value of life to be bordering on psychopathic. But NICE is not in the position of an individual person reflecting on life and death. It is a public agency charged with spending certain public resources in the best way possible. And we do not generally expect such bodies to make decisions based on emotion.  This is true even of public decision-making agencies which, like NICE, are dealing in matters of life and death: for example, the Highways Agency, the Police, and air safety regulators. Would the Mail also like to see the Civil Aviation Authority adopt a less "clinical" approach to aircraft safety?

One reason why we would find a less clinical, more emotional approach inappropriate in these areas is the simple fact that it would lead to worse decisions. The same would seem to apply to NICE. If decisions were made on emotion, then we might expect all sorts of irrelevant personal preferences and idiosyncrasies to influence decisions. A less clinical decision-making process would also be more susceptible to interference from powerful but non-beneficent interests. A virtue of the current system is its transparency.

If the Mail has a problem with NICE’s judgement about the Kidney Cancer drugs, then it should point out what, specifically, has gone wrong in the decision-making process in this case.


Daily Mail Comment, ‘How can the NHS put a price on life?The Daily Mail, 6 August 2008.

National Institute for Health and Clinical Excellence (NICE), Social Value Judgements: Principles for the Development of NICE Guidance. Second edition. 

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