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It’s not NICE to discriminate
  1. John Harris
  1. Correspondence to:
 John Harris
 The Centre for Social Ethics and Policy, Institute of Medicine, Law and Bioethics, School of Law, University of Manchester, Williamson Building, Oxford Road, Manchester, M13 0JH, UK;

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NICE must not say people are not worth treating

The National Institute for Health and Clinical Excellence (NICE) has proposed that drugs for the treatment of dementia be banned to National Health Service (NHS) patients on the grounds that their cost is too high and “outside the range of cost effectiveness that might be considered appropriate for the NHS”i.1

This is despite NICE’s admission that these drugs are effective in the treatment of Alzheimer’s disease and despite NICE having approved even more expensive treatments. The effect is that thousands of Alzheimer’s patients will be denied the only treatment available. It is difficult to think of this as anything but wickedness or folly or more likely both. At the same time, and with no apparent sense of irony, NICE has launched a public consultation document3 on its guidelines on social value judgments. As we shall see these guidelines are ethically illiterate as well as socially divisive.

Assuming permanently scarce resources it is clearly crucial that such healthcare resources as are available are not wasted. This point is often made in terms of cost effectiveness and it is argued, not implausibly, that to talk of cost effectiveness implies that we are able to measure just how cost effective each treatment is. To do so of course we need a standard of measurement. NICE has adopted the ubiquitous, but justly infamous QALY, the Quality Adjusted Life Year.

The QALY combines life expectancy after treatment with measures of the expected quality of that life. There are two ways in which QALYS can be used. They might be used to determine which of rival therapies to give to a particular patient or which procedure to use to treat a particular condition, in short which of two different treatments is the more …

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  • i I first wrote about the inequities and iniquities of QALYs in 1987.2

  • ii I argued this in detail in an article published in the BMJ in 1997.4

  • iii I first articulated this principle in a chapter in Textbook of Geriatric Medicine and Gerontology. Its present name, however, the age-indifference principle, was suggested by a member of the working party established by the international charity, Age Concern, to investigate attitudes and values in relation to ageing.7

  • iv See also an article by Simona Giordano in a recent issue of the Cambridge Quarterly of Healthcare Ethics8 and for more sources see Elizabeth S Anderson’s paper in Ethics.9

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