The Egalitarian Cruelty of the NHS


Even if you're accustomed to hearing horror stories about Britain's National Health Service, this one is really appalling. Debbie Hirst, a woman with metastasized breast cancer, wanted to take Avastin, a drug that, per The New York Times, is "widely used in the United States and Europe to keep such cancers at bay." The NHS refused to pay for it, saying it was too expensive. That much is par for the course in a system that holds down costs by rationing care according to standards set by a single central authority. But then Hirst, with the support of her oncologist, decided to raise the $120,000 she'd need to pay for the drug on her own, mainly by selling her house. The NHS said she was perfectly free to do that, but then she would have to pay for all of her care out of pocket, a financial burden that was far beyond her means. The Times does its best to explain the rationale for this position:

Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.

Patients "cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs," the health secretary, Alan Johnson, told Parliament.

"That way lies the end of the founding principles of the N.H.S.," Mr. Johnson said.

Yet if you are wealthy enough to pay for all of your health care out of pocket, you are allowed to do so. Doesn't that also give richer patients an unfair advantage over poorer ones? Why isn't that equally offensive to the egalitarian sensibilities of NHS bureaucrats? The fact is, it's better to be rich than poor for many reasons, and fairness doesn't really enter into it (assuming the absence of force or fraud), unless you view all resources as the government's to distribute as it sees fit. And even a collectivist would have to admit that the NHS policy that Hirst ran into makes little sense:

In fact, patients, doctors and officials across the health care system widely acknowledge that patients suffering from every imaginable complaint regularly pay for some parts of their treatment while receiving the rest free.

"Of course it's going on in the N.H.S. all the time, but a lot of it is hidden—it's not explicit," said Dr. Paul Charlson, a general practitioner in Yorkshire and a member of Doctors for Reform, a group that is highly critical of the health service. Last year, he was a co-author of a paper laying out examples of how patients with the initiative and the money dip in and out of the system, in effect buying upgrades to their basic free medical care.

"People swap from public to private sector all the time, and they're topping up for virtually everything," Dr. Charlson said in an interview. For instance, he said, a patient put on a five-month waiting list to see an orthopedic surgeon may pay $250 for a private consultation, and then switch back to the health service for the actual operation from the same doctor.

"Or they'll buy an M.R.I. scan because the wait is so long, and then take the results back to the N.H.S.," Dr. Charlson said.

In his paper, he also wrote about a 46-year-old woman with breast cancer who paid $250 for a second opinion when the health service refused to provide her with one; an elderly man who spent thousands of dollars on a new hearing aid instead of enduring a yearlong wait on the health service; and a 29-year-old woman who, with her doctor's blessing, bought a three-month supply of Tarceva, a drug to treat pancreatic cancer, for more than $6,000 on the Internet because she could not get it through the N.H.S.

In the end, after Hirst's cancer spread even further, the NHS decided the balance of costs and benefits had shifted, and it agreed to pay for her Avastin:

Mrs. Hirst is pleased, but up to a point. Avastin is not a cure, but a way to extend her life, perhaps only by several months, and she has missed valuable time. "It may be too bloody late," she said.

"I'm a person who left school at 15 and I've worked all my life and I've paid into the system, and I'm not going to live long enough to get my old-age pension from this government," she added.

She also knows that the drug can have grave side effects. "I have campaigned for this drug, and if it goes wrong and kills me, c'est la vie," she said. But, she said, speaking of the government, "If the drug doesn't have a fair chance because the cancer has advanced so much, then they should be raked over the coals for it."

Hirst had no choice about paying the taxes that support the NHS, and when she tried to supplement the limited coverage it provided out of her own pocket, it reneged on its promise to take care of her. The Michael Moores of the world surely would see injustice in a decision by an HMO or insurer not to cover a cancer patient's Avastin. Why don't they see injustice in a case like this?

Michael Moynihan on Michael Moore and the NHS here, here, and here, among other places.