Abstract
CHAT has its limits. It is a three-hour exercise. However, the real world problems of healthcare rationing and priority-setting are too complex for a three-hour exercise. What is needed, as a supplement, are sustained processes of rational democratic deliberation that can address the challenges to healthcare justice posed by costly emerging medical technologies, such as these targeted cancer therapies.
Highlights
In the United Kingdom, the National Institute for Clinical Excellence (NICE) is responsible for determining whether or not these targeted cancer therapies will be funded by the National Health Service (NHS), which has a fixed annual budget, unlike Switzerland and many other countries, including the United States
NICE is entirely independent of the British government, which gives it immunity from political pressure
Is that a good or just use of limited social resources? Could other healthcare needs have been met that would have yielded more health good for more persons at a lower cost per QALY? Should we ignore that question because these lung cancer patients are faced with a terminal outcome in the near future? 80% of Swiss CHAT participants wanted to exclude from coverage “invasive life-sustaining measures in dying patients.”
Summary
Our “sense of justice” is complex and very much context-dependent, which again requires sustained public deliberation to fashion a considered judgment of healthcare justice specific to some concrete rationing problem. Most of the targeted cancer therapies and immunotherapies used to treat metastatic cancers are not cost-effective (using $100 000 per quality-adjusted life year [QALY] as the threshold) nor do they yield clinically meaningful benefit (though we note that no public deliberative process or legislative policy in Switzerland has endorsed any such number, whether higher or lower).[2,3] On average, most of these targeted therapies yield survival gains measurable in months, not years, with costs ranging from $100 000 for a course of treatment to more than $500 000 (for CAR T-cell therapy for B-cell lymphoma).[4] In one study only 13 of 37 of these targeted cancer therapies met the threshold of the European Society of Medical Oncology for clinically meaningful benefit.[5] Should we conclude from that research that Swiss CHAT participants would give up socially funded access to all these cancer therapies that were not cost-effective and did not yield clinically meaningful benefit?
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