Prof Ray Tallis' reply to the letter from Gillian Tindall

Dear Editor,

I am very grateful to Gillian Tindall for her letter 'On Tallis' Difficult Moral Questions' (HealthWatch Newsletter 69) because it gives me the opportunity to make one or two points that could not be accommodated in an article which kept to the commissioned length,

The issue of cost-effectiveness is a very vexed one. It is difficult - but not impossible - to calculate comparative cost-effectiveness of different drugs or, more broadly, health technologies. If finite resources are available, then it is not merely appropriate, but, or so it seems to me, morally imperative to ensure that more cost-effective technologies are favoured over less cost-effective ones. By that means, we will ensure that resources made available to the NHS deliver maximum health gain. Of course, things are not quite so simple as that. Firstly, many treatments have slipped through 'on the nod' without being exposed to cost-effectiveness evalution. Secondly, it is evident from NICE's decisions that the use of NHS resources is not nakedly utilitarian. I am pretty sure that if we lowered the upper limit at which technologies are available on the NHS to below £30,000 per QALY, we would get more value for money. The world, however, would be a crueller place. Thirdly, there is the issue of 'orphan diseases' such as congenital enzyme deficiencies which, in virtue of their rarity, are always going to expensive to treat. (Drug companies will charge more for drugs for which there is a small market). Finally, there is the politico-ethical question as to how much taxpayers are willing to pay in order to fund each others' need for care. I discussed all these issues in a paper I gave to the Royal College of Physicians at a session chaired by our President Nick Ross. One of the conclusions I drew was that not even a John Rawls approach, based upon the notion of distributive justice, would solve the dilemmas faced by NICE. In the absence of a solution to the ethical issues, we have to be pragmatic and try to move towards the most cost-effective use of existing resources. Saying 'Yes' to things that don't work or offer very little would mean saying 'No' to things that do work or work better.

As regards Gillian's second point, I may have been misunderstood. I was not suggesting that we should sacrifice individuals to the greater good - we know where that leads - but acknowledge that a treatment that works extremely well in most people, and thus brings overall benefit to the population being treated, may have unacceptable adverse effects in a small minority. Where the media sometimes fail is that they may focus on the latter and overlook the former. I for example have had very unpleasant experiences with statins and cannot tolerate them. It would be wrong if, on the basis of my unhappy experiences, I were to launch a media campaign against statins which seem (so far) to be delivering huge health benefits to other people with high cholesterol. We should not ignore, or over-ride, individual experiences; indeed, the experience of those who feel a treatment has injured them or their loved ones should prompt review of the evidence of overall benefit.This is what post-marketing surveillance is all about.

Your sincerely

Raymond Tallis