New drugs may be more effective than existing treatments, but many are very expensive and may not be available through publicly funded health schemes.

This raises several ethical dilemmas for doctors. Is it reasonable to ask a patient to finance the full cost of their treatment when it is not provided by government? Would it be unethical to raise the option of treatment with an unsubsidised drug?

Researchers surveyed 184 Australian cancer specialists about their opinions and practices regarding potentially useful but unsubsidised drugs.

A large proportion said they would not discuss an expensive drug with a patient if it were not subsidised because of potential psychological and emotional effects that these discussions might have on patients and their families. The survey also found that these discussions were stressful for clinicians.

But the authors argue that this practice fails to respect autonomy and may not be in the patient's best interests. They believe that withholding information on the basis of what a patient would want is "a dangerous medical path to unjustified paternalism."

A further ethical issue concerns the cost of publicly funding newer, expensive treatments, they write. This is an urgent question of distributing limited resources fairly that faces not just new drugs, but many forms of modern technological care. "The gap between what we can do and what we can afford will continue to grow, at a personal and community level."

The issue of accessing new expensive drugs has no easy solution, they say. Nevertheless, it seems unreasonable to withhold information from a patient about any potentially beneficial treatment because of concerns about capacity to pay, even if these discussions cause distress for some patients. '"/>

Contact: Teresa Hagan
thagan@bma.org.uk
44-20-7383-6174
BMJ-British Medical Journal
3-Nov-2005