LEADING ARTICLE: Hard choices: but who decides?

Most people have no difficulty deciding whether B, the 10-year- old Cambridgeshire girl dying from leukaemia, should be given the treatment that might just conceivably save her life. Of course she should. If there is even a remote chance of her beating the disease, so the argument goes, she should be provided with the necessary treatment. After all, given the amount that we spend on weapons and all we waste on unnecessary consumption, who could possibly deny the £75,000 needed to pay for chemotherapy and a bone marrow transplant? The cost comes to less than 0.15p from every member of the population. Surely we have not become so mean-minded, when we are richer than ever, that we cannot afford even this slight generosity?

From this point of view, yesterday's courtroom wrangling between the girl's parents and Cambridgeshire Health Authority looks obscene. It was, however, a glimpse of the real world in which armies will not disband, nor taxpayers scrimp and save in the cause of state philanthropy. It is a world in which hard choices must be made about how to apportion limited funds. Giving children such as B their slim chances has a cost in terms of other deserving patients who may be deprived of treatment that they would otherwise have received.

These choices are not new, but in the past they were made in private by doctors, the high priests of medicine, who discerned the "right" course of action and were not expected by lesser mortals to justify their decisions. They couched their judgements solely in clinical terms, but everyone within the profession knew and accepted that money was also a factor in establishing priorities.

So however traumatic yesterday's court case was, it did not mark a descent into a new heartlessness. It in fact represented a welcome openness in which an important reason for rationing treatment - the cost - was made plain in an honest and open manner. Judges, politicians and the public have at last become embroiled in a dilemma that they might at times wish they could have left to the clinicians.

There are many issues raised by B's case beyond money. Her plight highlights the fact that we now find it almost impossible to envisage that a child's life sometimes cannot be saved. As infant mortality rates have plunged, medical technology has advanced and the expectations of adults have grown, the death of a child has become unacceptable. Sometimes parents and physicians fail to recognise when they should savour what is left of a child's life rather than trying to extend it further at a high cost to the child in terms of suffering.

But the more general and enduring question posed by the Cambridgeshire case is: who should have the final say over NHS spending? This issue lies behind a host of controversies, ranging from the planned closure of London hospitals to the row this week about an accident victim who had to be flown from Kent to Leeds in search of a hospital bed.

The NHS changes mean that health authority purchasers - managers advised by clinicians -make crucial decisions that may decide who lives and who dies. When treatment for B was being considered, the hospital in question had to ask Cambridgeshire Health Authority whether it was prepared to fund a special contract for the work.

The case demonstrates that these health authorities are at least open to question by the courts. But the public, which provides the funds, knows little of what determines the choices that are made. The group of individuals that chooses between, say, buying more hip replacements or extra coronary bypass operations is shrouded in mystery and obscurity. Yet health authorities now rank among the most important institutions in the country.

The issue of health priorities has become highly politicised. Once, decisions were the preserve of the doctors. Now they are fought out in the courts, in Parliament, on television and in the press. But the key decision-making bodies in the NHS do not as yet enjoy public confidence. The only way forward is a more transparent and accountable NHS - perhaps with an elected element among its officials - in which ordinary people play their part in setting priorities. This would mean that none of us could shirk responsibility for harsh choices that will have to be made about who gets what in the future NHS.