Ethics and Public Policy by Andrew Bradstock

Author:Andrew Bradstock
Language: eng
Format: epub
Publisher: Victoria University Press

9

Making Fair Funding

Decisions for High-Cost

Health Care: The case of

Herceptin in New Zealand

Elizabeth Fenton

Resource allocation and high-cost cancer care

Ethical issues surrounding the distribution of scarce health care resources are often discussed at the micro level, where it must be determined who of a number of identified candidates should be allocated a particular scarce resource first, raising clear and difficult issues of fairness and distributive justice.1 Less clear perhaps, but no less difficult, and just as morally significant, are macro-level decisions made every day worldwide by policy makers about how national health budgets should be set and divided up. The attention paid to the ethical issues involved in this latter form of resource allocation is growing, in part because of dramatically rising health care costs. One area in which this issue is particularly acute is cancer care, where cost increases have resulted in treatments whose price tags can exceed the median United States household income.2 Anecdotal evidence suggests that this trend is set to continue, with the ‘pipeline’ at one pharmaceutical company said to contain no cancer drugs priced less than US$300,000/QALY (Brock, 2009).3 Not surprisingly, questions are being raised, both by oncologists and by policy makers, about whether these costs are justified. While oncology is not the only area of health care in which costs are increasing, it has become something of a lightning rod in the debate over health resource allocation, in part because the costs of emerging drugs are so high, in part because of the sometimes limited or uncertain proven effectiveness of the drugs, and in part because cancer is a ‘dreaded disease’ from which people seek protection at any cost. For these reasons cancer care raises new and unique issues for the debate over how limited health care resources can be allocated most fairly.

The difficult allocation issues engendered by high-cost treatments are ubiquitous across all health systems, public and private. Even, or perhaps particularly, where health systems are willing and experienced in negotiating with pharmaceutical companies on drug prices, and have adopted explicit rationing and prioritisation processes, debate over the funding of expensive cancer drugs has been heated. In New Zealand, where limit-setting is not only publicly acknowledged but built into health care legislation (Manning and Paterson, 2005), controversy over the funding decision for the drug Herceptin for HER2-positive early-stage breast cancer has been significant. Placing New Zealand in a tiny minority of OECD countries, the government pharmaceutical agency, PHARMAC, decided to fund Herceptin for 9-week courses of treatment as opposed to the more common 12-month courses. This decision was motivated by the high costs of Herceptin coupled with, on PHARMAC’s interpretation, the inconclusive evidence of additional effectiveness of the longer treatment course. By funding the drug for 9-week courses PHARMAC made the most cost-effective decision, balancing limited resources against the importance and potential of this new drug. Yet the agency was harpooned in the media by the powerful and frustrated breast cancer lobby, which decried the decision as ‘cruel’, ‘shameful’ and ‘inhumane’ (Borley, 2008). This criticism

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