The Hastings Center Report has published an interview with a representative of the Orwellian-named NICE (National Institute for Health and Clinical Excellence), the UK’s rationing board. The interview pretends that all NICE does is issue recommendations, that the NHS Trusts are free to take or leave. While that may be technically true, practically it isn’t. That is why NICE is sometimes sued, because what it recommends almost always becomes official policy.
NICE cannot ban anything. It issues guidance, in the form of both clinical and public health guidelines, and on the use of technologies like drugs and medical devices. The guidance specifies the technologies in question, their dosages and frequency of use, the stages of a disease at which their use is most appropriate, counter-indications, and the patient groups for which they are likely to be effective. Local health care purchasers and providers must make any technology recommended by NICE available when it is required by a local physician. In this sense, NICE enables rather than commands – only physicians have powers to command…
NICE’s guidance to professionals is just that: guidance. The general expectation is that most professionals will follow the finest advice and guidance that can be mustered to support their work. This seems the right approach to m – the best way to encourage best practice is to provide the best information.
Needless to say, since it is profoundly utilitarian in outlook, it uses quality of life judgments in issuing its “recommendations:”
NICE recommends the use of a version of the Quality-Adjusted Life-Year as its principal outcome measure (EQ-5D), partly to enable NICE advisory committees to make consistent comparisons between the many possible procedures that could be included in the “benefits basket” and partly to encourage researchers to use that outcome wherever appropriate. The QALY is not itself, a criterion. It is only the denominator of the incremental cost-effectiveness ratio.
NICE understands that it is a trailblazer and that similar “recommending” utilitarian/quality of life/cost containment bodies may soon be coming to a health system near you:
With passage of time – and the likely creation of NICE look-alikes around the world – an important new determinant of research patterns in industry seems likely to emerge. For the first time, strong indications will exist about the types of research-based products entire systems are willing to pay for and which will therefore generate returns for innovators. If this generates, as it should, incentives to invent new products that are cost-effective, then that will be one significant strand in the universal striving for both better health and cost containment.
If that doesn’t scare you, nothing will.
The interview headline asks whether NICE is nice: No, it isn’t. If Hippocratic medical values are to survive, we must fight these natioanl bioethics oversight boards with all our might.
June 23rd, 2009 | 6:13 pm
Pretty cool post. I just came across your site and wanted to say
that I’ve really liked reading your blog posts. Anyway
I’ll be subscribing to your feed and I hope you post again soon!
June 23rd, 2009 | 10:27 pm
NICE was the acronym C.S. Lewis used for the orwellian bureaucracy in one of his science fiction novels. Hmmm. It is beginning to happen.
June 24th, 2009 | 12:30 am
It seems odd to me that this organization should have chosen the same acronym as the diabolical planning organization in “That Hideous Strength” by C.S. Lewis.
In that book, NICE was the “National Institute of Coordinated Experiments,” with the secret goal of changing human nature through all kinds of utilitarian directed social controls. I think it was controlled by some kind of odd diabolical disembodied head that secretly controls those who believe they are the most powerful members of the inner circle.
Makes you think…
June 24th, 2009 | 5:50 am
My comment was also about the using of the acronym N.I.C.E. Is it ignorance of the works of the great C.S. Lewis or is it just arogance?
June 24th, 2009 | 9:06 am
From the practical sense, NICE is just doing triage. Ideally we’d like to help everyone, but we just don’t have the capacity. This argument is very persuasive for politicians and law makers.
From a human sense, there’s a huge difference. In triage, you have to see all the faces of those you condemn and you can provide confort to those you cannot help.
In NICE, some ivory tower academic and some far off beaurocrat decides that patent #101 doesn’t match the criteria, therefore does not qualify. Nothing more. Nothing less. You are just a impersonal number.
This argument is unfortunately not persuasive for law makers and politicians, but is persuasive with the anyone with a heart and the artists, so there still is hope.
June 24th, 2009 | 10:43 am
Ralph Davis: Thanks for stopping by. Triage, by definition, is a temporary measure that doesn’t value some lives over others. What NICE does–and the NHS and rationed care–is determine that the value of some patients is worth more than others, and people are denied care even if there is no pending emergency. It is inherently discriminatory. It also strikes me, that at least in the USA, we don’t have a shortage of resources but priorities. I notice that we are pushing this boondoggle, but not cutting in other less urgent areas. We just want it all and we don’t care that it is a big Ponzi scheme.
Mark: Vilkommen. I doubt they have read CS Lewis novels. It would hit too close to home.
June 24th, 2009 | 1:18 pm
Wesley, being from a country that has public health care (Canada), I disagree that it’s a Ponzi scheme. There are real benefits, but I won’t regurgitate all the arguments since you’ve probably heard them before.
Yes, the US is a rich country, but the reality is, to do all the things the US *should* do — health care being just one aspect of this duty, it would need a GDP per person that was at least an order of magnitude higher than it currently is and it would need to stop “pointless spending”.
WRT triage, you’d like it to be temporary but realistically it’s not. Go to any hospital emergency room in any country and you’ll see a triage unit which prioritizes patients based on various criteria. In some countries, it’s who can pay the most. In others, (e.g. Canada) it’s who needs help sooner and who can wait and try to reduce the need for health care by promoting prevention. In others, it’s (unfortunately) based on ethnicity. In NICE, it seems to be “how much can you give back to society if I decide to cure you”.
This is precisely the problem I was trying to express. I disagree with the “you have value only if you’re rich enough” of the current US system. It is, essentially little different than the NICE criteria….you’re just a number put into a cost/benefit equation. But NICE is worse since, in the current US case, since in the current US, there is room for the doctor or hospital to move beyond the mammon value of a person and donate his/her services through compassion to the individual. With NICE, that’s not an option since defying NICE is “morally wrong” since you’re working against “society”. The person is irrelevant. The institution is all that counts. In current US system, doctors feel the pain of rationing face to face and try to work towards reduction of the rationing. In NICE, there is no problem to be solved and justification for further rationing since a society that “gets rid of it’s dead wood” is a lot more “efficient” than one doesn’t.
June 24th, 2009 | 2:16 pm
Ralph: I didn’t call public health care a Ponzi scheme. I was referring to what is happening here, with the govt. going into debt to bail out other sectors of debt. Sorry for the confusion.
But you are mistaken about US health care. The overwhelming number of people are very satisfied with the health care they receive. Poor people here get health care via Medicaid. People without insurance are cared for in time of need, too often from ERs. But there are also health clinics and etc. It isn’t just the rich who get cared for. In fact, considering that Canada sends Canadians to the USA to give birth and your “rich” come here so they don’t have to wait three years for surgery, I would warrant that our systems is better for more people. Indeed, even though Canada has guaranteed care, millions can’t get their own doctors.
Our problem is the uninsured. Millions of these are illegal aliens. We can’t afford to pay for them, and doing so would open the floodgates of people coming here for health care on our dime. Some choose to buy big screen TVs rather than buy health insurance. I have some sympathy, therefore, with the idea of required insurance (assuming subsidies and/or tax credits) to assist people in paying.
It seems to me the biggest problem that needs addressing is cherry picking by private companies refusing to insure people with preexisting conditions. That needs to be dealt with, perhaps through a system like in auto insurance in which uninsurable drivers (assigned risk) are able to obtain coverage the cost of which is subsidized by a pool of insurance companies chipping in.
Public health costs, I believe, are rising faster than private health costs. Thus, we also need price competition at the level of the patient.
So, it is complicated, but having the Feds pay for everything will end up like Canada, rationed like Oregon Medicaid, or the UK.
We need reform, but not the kind we are looking at.
Thanks for being here.
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