There was good news for thousands of patients last week when the Ontario government announced it had earmarked $50 million to cover the costs of cancer treatment drugs Avastin, Sprycel and Alimta.
The announcement, however, raised important medical ethics issues: who gets treatment, and how do we decide?
“Governments are terrified of this stuff,” says Margaret Somerville, a medical ethicist at McGill University.
Dr. Brian Day, president of the Canadian Medical Association, warns that as the Canadian medical system moves away from hospital-based care to more drug-based treatments – plus gene therapy procedures and stem cell remedies just over the horizon – pressure on governments to fund ever-more expensive procedures will only build.
But providing every available procedure to every patient who might need it would bankrupt medicare, he warns. Better, he says, to figure out a way to ration treatment to ensure universal health care remains available to all.
To understand his point, try picturing a lifeboat. It holds 60 people, but there’s only 50 on board. Dozens of people are swimming just metres away, struggling to keep their heads above water. The question is, who do you bring on board, and why?
That, in overly simple terms, is the growing dilemma facing the medical profession, the governments that finance it and, ultimately, all of society. The people in the water represent cancer patients. The extra 10 seats on the lifeboat represent the ability to save only some of them.
Day would like to see a national body of experts set up that would make non-binding recommendations about who should be eligible to receive expensive new treatments and who shouldn't.
Somerville agrees that some sort of procedure might be needed, but points out that the essential ethical issues still need to be dealt with. She divides the issues into generally micro and macro categories.
On the micro level, she says, there are individual patients who need the treatments. It would be unethical, she says, to deny them. On the macro level, however, there's the question of whether the money spent to help such patients might be better used to help the overall medical system.
"You can get conflict over what's ethical at one level and what's ethical at another," she says. "That's when we end up in a knot about all this."
Day says that in the absence of a meaningful discussion about rationing, we end up with a "self-rationing" medical system of long waiting lists, crowded emergency rooms and patients with no family doctor.
Canadian Health Coalition director Michael McBane fears that decisions on who gets care depend more on the pressure applied to politicians than anything else.
"If they don't get embarrassed in the media, they don't move," he says.
Day says the issue will only get bigger in coming years as new treatments come available and baby boomers age, putting added strain on the medical system. At the same time, he says, the number of taxpayers left behind after the boomers retire may not be enough to maintain the system.
"In 20 years time, I am going to be in my early 80s and demanding more healthcare, but there won't be enough taxpayers to pay for it," he says.
"Society just isn't ready for this."