The ethics of private payment for healthcare: the example of vaccination
19 Sep 2013
In July 2013 Julian Savulescu, Uehiro Professor in Practical Ethics, blogged about the Joint Committee and Vaccination and Immunisation’s decision to reject a vaccine that would protect children from Meningitis B. The Independent newspaper has published the viewpoint of a twelve year old girl who lost her leg as a result of the disease, which sets Julian’s original blog in a very human context.
A vaccine which would protect children from Meningitis B has been rejected by the British government's Joint Committee on Vaccination and Immunisation (JCVI) as not cost effective, despite the fact the cost is not yet known.
The Department of Health’s director of immunisation explained: “This is a very difficult situation where we have a new vaccine against meningitis B but we lack important evidence. We need to know how well it will protect, how long it will protect and if it will stop the bacteria from spreading from person to person.
“We need to work with the scientific community and the manufacturer to find ways to resolve these uncertainties so that we can come to a clear answer.”
A call for more research is a standard answer to many dilemmas in healthcare, though perhaps one which is easy to ignore. As far as we know there are no current plans to ensure that this research takes place but the vaccine has already been found to be safe, and according to the BBC, “tests have suggested the vaccine is effective against 73% of the different strains of the disease”.
Resource allocation is an inevitable part of any health care system, and perhaps especially so in the NHS. Whilst we would like to provide all available treatments, prioritizing according to effectiveness and cost is necessary, though the exact method of calculating this (currently Quality Adjusted Life Years, or QALYs) is of course under intense debate and scrutiny.
In the meantime, children continue to suffer avoidable, lifelong disability due to infection with Meningitis B. I argue with Lach de Crespigny in a forthcoming paper on homebirth that actions (or failures to act) taken today which cause harm in the future are as wrong as if that harm were realised today. The plight of these children and adolescents should not be ignored.
Put simply, if you could prevent a child from getting brain damage, now or in the future, at little cost to you, you ought to perform that act.
One possible way forward would be to allow parents to pay for the vaccination of their child, at whatever price the company sets, just as holiday vaccinations can be provided by the NHS at a cost to the patient. Vaccinated children could be monitored and their data recorded. Not only would this generate the data that would establish how high up funding agendas this vaccine should be, but some individual children would be prevented from suffering this deadly and debilitating disease. To increase take up, the company would be under market pressure to keep the price as low as possible.
Of course, not everyone could afford the vaccine, and this would introduce some inequality into health care. But they would be more likely to receive the vaccine in the future if data shows that it is effective (and cost effective), and in any case are no worse off than under the current regime.
Another ethical point about paying for vaccination is that, even when it cannot be afforded by all, there are still benefits to those who can’t afford the vaccine. If enough people bought the vaccine , herd immunity might be induced and protect at least some of those who couldn’t afford it. Coverage might not be high enough to have a big impact, and we don’t really know whether or how well this vaccine induces herd immunity.
Parents are free to pay for safer cars, to pay extra for homes in safer areas, and to take various other expensive measures to ensure their child’s safety. Yet not everyone can afford these measures. Allowing the purchase of a vaccine would be another way which parents could increase their own child’s safety, if they had the means and decided to use them in this way.
It may be inevitable that we work in QALYs at a national level. But we should be free to choose how much to pay for the small chance of avoiding a major harm at an individual level.
Increasingly, the NHS will have to give up the myth that it can provide universal health cover for all for all effective interventions. Increasingly, some interventions will be too expensive to offer within a public health system. But patients must know their options. There is evidence that doctors paternalistically (or for ideological reasons) fail to inform patients of all available options, such as high cost chemotherapy (1). This is an unethical failure to respect autonomy.
The best place to start in offer privately funded health care options is vaccination, since it promotes herd immunity and has beneficial effects for those who cannot afford it.
- References: L. R. Mileshkin, P. Schofield, M. Jefford, E. Agalianos, M. Levine, A. Herschtal, J. Savulescu, J. Thomson, J. R. Zalcberg, (2009). ‘To Tell or Not to Tell?: The Community Wants to Know about Expensive Anti-cancer Drugs as a Potential Treatment Option’. Journal of Clinical Oncology. Vol: 27 no. 34 pp 5830-5837
This opinion piece reflects the views of the author, and does not necessarily reflect the position of the Oxford Martin School or the University of Oxford. Any errors or omissions are those of the author.