Medical Life

Should breasts be provided on the NHS? That was the question before the appeal court last week after a patient undergoing a male-to-female sex change complained about the results of her treatment.

She had received hormone treatment but regarded the outcome as cosmetically inadequate and wanted implants to surgically enhance what the hormones had produced.

Her NHS trust, which had already fought and won the case in the High Court, protested that it did not offer surgical enhancement to other women on the NHS. But the patient insisted that hers was a special case as she was "becoming" a woman.

As NHS budgets tighten, ethical dilemmas proliferate. Critics have pointed out that it would have been cheaper to pay for the treatment in this case than to fund a costly court action. But the NHS trust maintained that a principle of equity was at stake. If it had conceded, it feared an avalanche of demands for better breasts from women disappointed with what nature had given them.

Attempts to ration health care are always troubling. However rigorous the procedure, when the axe falls and a treatment or service or hospital disappears, there is an outcry. Look at NICE.

Some trusts, like this one, take it seriously, appointing a "priorities committee", guided by an "ethical framework".

Others are less scrupulous. They make decisions on an ad hoc basis, as the need arises. If you want a quiet life, rather than cutting high-visibility sex changes, why not go for low-visibility wheelchairs and daycare centres?

When times are hard, the need for scrutiny increases. Imperial College, London is conducting a patients' survey of attitudes to rationing by circulating a questionnaire to people as they languish in their hospital beds.

As you lie there, recovering from brain surgery, guiltily wondering if you are a deserving case, it asks: "If the NHS cannot treat everyone, who should decide who gets treatment?" Should treatment be rationed for asylum seekers, illegal immigrants or criminals?

Finally, it seeks rankings for six patients in the order in which they should be treated, including an infertile 40-year-old couple, a 50-year-old man unable to work because of painful joints, a 24-year-old in need of an artificial leg, an eight-year-old girl needing plastic surgery for her disfigured face and an 80-year-old no longer able to cope at home and in need of nursing care.

Would any health service that required such choices to be made still deserve the title of National Health Service?

Welcome to a brave new world.