Medical life

As protector of the NHS's purse, the National Institute of Clinical Excellence (NICE) does a fine job. It assesses drugs and treatments, filtering out those that don't represent good value for money, approving only those that do.

Why then is it recommending a treatment be made available to patients who request it, at a cost hundreds of pounds greater than the alternative, and which is of no medical benefit?

I refer, of course, to its guidance on caesareans, published last week, which says women who request the procedure, in the absence of any clinical indication – physical or mental – for it, should be offered an opportunity to discuss the risks and benefits, after which, if they still want it, they should be allowed to have it.

The upshot is that some women will have caesareans that are medically unnecessary. There is nothing wrong with this. It should be the patient's right to decide what is best for them. The previous version, published in 2004, took a paternalistic stance, asserting that "maternal request" was not on its own an indication for caesarean section and could be declined by a doctor.

But a planned caesarean costs £2,369 – 42 per cent more than the £1,665 cost of a vaginal birth. How does NICE defend the spending of an extra £704 on each woman who opts for a planned caesarean where the operation is deemed medically unnecessary? That is £704 not available to spend on medically necessary treatments for other patients.

In other areas of medicine we draw a distinction between what is medically necessary and what is done for cosmetic or lifestyle reasons. Women who have breast surgery for cancer can have a reconstruction on the NHS. But if they want larger breasts, that is deemed cosmetic and must be paid for.

Men with erectile problems can get Viagra on the NHS if they are caused by a limited range of medical conditions such as diabetes. Otherwise they have to pay.

A woman who chooses a caesarean that is not clinically indicated is making a lifestyle choice – and she should pay.

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