Letter: Girl B is victim of the internal market's climate of mistrust

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Sir: It may prove helpful to address the issues raised by the debate on treatment for the 10-year-old girl with leukemia in two stages. The first question should be: if there were no limit on resources, would aggressive treatment, on balance, be recommended for this patient? Only if the answer to that is yes, does the second question of resource availability arise.

Here we enter a very difficult debate. It is generally accepted among health authorities and public health doctors that one aim of resource allocation in the NHS should be to maximise health gain, ie, to allocate health resources to those treatments which produce the greatest increase in health per pound. However, this apparently rational, utilitarian approach has been challenged on a number of counts, including equity and possible discrimination against those with existing disabilities.

But most relevant here is the "rule of rescue", defined by the American David Hadorn as "the strong human proclivity to provide aid to identified victims of illness or accident". Presented another way, this can be seen as insurance against catastrophe - most people would hope that their contribution to the NHS, as a member of society, would ensure that if they, as an individual, needed emergency treatment costing £100,000, say after a road accident, this would not be denied on the grounds that it was not cost-effective. The debate is further complicated because treatment outcomes can only be forecast in terms of probabilities and not certainties - a fact far easier to deal with on a collective than on an individual patient basis.

This area as a whole is very difficult, with no obvious resolution. However, if society's values are that the rule of rescue is important, to ignore this in decision-making could be seen as irrational.

A national debate is needed, not only to determine what resources we as a society wish to devote to health care, but also to understand and clarify the values that should enter resource allocation decisions. The utilitarian maximisation of health gain, while an important component, may prove to be an insufficient guide.

Yours sincerely,


Health Services Management Centre, School of Public Policy

University of Birmingham