Last Night's Television - The Price of Life, BBC2; True Stories: Tears, Tiaras and Transsexuals, Channel 4

Just the right treatment
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The Independent Culture

It's an elementary mistake to think that a good documentary will always clarify the world for you. In fact, some of the best show you how intractably complicated it can be, a knot drawn so tight that there's no purchase for a fingernail. Adam Wishart's film The Price of Life was a good case in point, filming (for the first time on television) the deliberations of the National Institute for Health and Clinical Excellence (Nice), the body that has to decide whether a drug should be approved for use by the National Health Service or not. It began with a relatively simple issue. We met a man, Eric Rutherford, who was dying from multiple myeloma and had been thrilled to hear about a new drug called Revlimid, which had proved in clinical trials to be much more effective than previous treatments. Should he receive the drug or not? Since Eric was a likeable man and his wife was eloquent about the distress his death would cause the answer to this question seemed straightforward, and the bitterness of his wife, Anne, at the prospect that he might be denied this new treatment understandable. "These are people who don't care," she said. "They'll save money at any cost."

Then the complications began to arrive. For one thing, Revlimid isn't a cure, just a postponement. As another doctor put it: "A drug that extends life for a year is a great cancer drug. But it's not like at the end of the year you're cured. At the end of the year you're dead." And since a course of Revlimid will cost over £35,000 per patient, saying yes to Eric's treatment isn't without its consequences for the hospital's budget. To paraphrase his wife's accusation – do we save Eric at any cost? And even if you answer yes to that question – as many people might – you have to remember that the cost has to be calculated not just in pounds, but in terms of the lives that won't be improved or even saved should Revlimid be approved.

This is where Nice comes in – with its unimprovably suggestive acronym. It's not a nice business this but it does involve nice judgements, in which human lives somehow have to be quantified and weighed against each other. Patients understandably flinch from the process: "They do not care... we're just numbers to them," said one, desperately hoping that Revlimid would be approved. To which one can only say, "Thank goodness". How else could such decisions be made? There will, no doubt, be viewers appalled by the committee chairman's brisk summation of one part of the discussion – "Is there anyone who disagrees with that... other than emotionally" – insisting that emotion should play a part. But it's hard to see how such an emotional audit would ever end, as the value of a newborn baby was weighed in the scale against the right to life of a much-loved grandmother.

Emotion – or subjectivity – creeps in anyway of course. Under the pressure of patients and lobby groups, Nice's rules of engagement were recently altered to allow it greater leeway in the approval of end-of-life treatments for terminal patients. It previously wasn't allowed to spend more than £30,000 for every extra year of life a drug might offer a patient. Now it can break that barrier if it sees fit (as it eventually did in the case of Revlimid). But breaking it means someone else will die prematurely – as a National Health Service administrator here pointed out with a bitterness that easily matched in moral force the anger of Eric's wife.

Bizarrely, a system that used to value a month of healthy vigorous life at a higher rate than a month of painful suffering now seems to have reversed its terms, so that a month of a terminal patient's life carries a premium of 1.4 over yours and mine (assuming you're lucky enough to be well). And we've scarcely had time to get into the moral tangle the pharmaceutical companies add, touting free-market dogma like revivalist preachers. "The most important thing to me is how quickly can we get this drug into the market," insisted Sol Barer, who runs the company that makes Revlimid. Drop your prices, Sol, and I think you might find it will happen a lot faster. And how exactly a free market is supposed to work if the customer isn't allowed to bargain hard – as appeared to be the case with Nice – is a mystery deserving of another documentary. I hope Wishart is commissioned to make it.

True Stories: Tears, Tiaras and Transsexuals wasn't complex. In fact, it could have been summed up with a belting chorus of "I Am What I Am", sung by big-boned women dressed, but only just in several cases, as human Barbies. Which isn't to say that this account of the world's first transsexual beauty pageant wasn't without its genuinely touching moments. I also enjoyed the rallying cry from Jahna (née Barry): "Ladies, come on, have some balls and let's get dressed up!"

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