Great Expectations

It is now one year since I was invited to write this column. As I look back over those twelve months and the forty-five resulting articles, I am struck by a recurring theme. Yes, I admit there has been the frequent mention of poetry and literature as I have attempted to combine those subjects with the art, science and politics of medicine. There has also been the occasional guest appearance of my wife; often as my ‘fall guy’ in introducing or illustrating a topic. However, there has additionally been a theme that Charles Dickens would have understood only too well: that of ‘great expectations’. In this case, not the personal expectation of one person, but the expectations of the community in respect to what medicine should, in the view of society, provide for that population as a whole. Such deliberations have covered concepts such as why society needs to decide what it wants from the NHS, how proposed changes to the NHS will fundamentally alter the service provided, and whether medicine as an organised profession is really useful to society in the first place. Some views have been personal, others widely held and accepted. However, as I consider the news of these past weeks, I am struck by another recurring theme; that of a duality of thinking within society.

By duality, I refer to the philosophical concept of dualism: being able to metaphorically look in two different directions at the same time, or consider two different and opposing views and be accepting of both; the sculptor Michelangelo was particularly good at introducing duality to some of his statues (e.g. that of Moses in Rome). The subject of recent articles exhibiting a duality of thought from a medical perspective has been that of cancer care and its funding.

Cancer is an emotive subject. It is one of the last disease groups to threaten our individual longevity, and it is therefore not surprising that headlines depicting early successes in cancer drug trials, new cancer drugs adding months to life, new ways of tackling the ‘cancer parasite’, and drives to reduce cancer screening ages, all give a sense of optimism to readers and an expectation of medicine (and by default, the NHS). However, those same headlines stare in the opposite direction to others that question the cost of the cervical cancer vaccine, query whether patients dying from cancer should continue to be given ‘futile’ drugs, and raise concerns that cancer treatment is increasingly unaffordable.

As a society, we have a serious problem to resolve. On the one hand, we all want to think that we will receive the best treatment for cancer, or that it will be available for every family member should the need arise. However, the reality is that cancer care is often prohibitively expensive, frequently experimental, and may only buy a small amount of time. Where cures are effected, many people are living longer and thus at greater risk of developing other forms of cancer. Some people alive today have survived two and sometimes three unrelated cancers, each with their own individual treatments and associated costs. Clearly, their survival is tremendous news for them; and it is what most of us would wish for as individuals. However, the significant question is whether society can continue to afford such care for everyone? At a possible £10,000 per month per patient, some economists say no.

The cost of treatment is a debate that is going to be a recurring theme. As a society, we need to stop having a duality of vision when it comes to care and cost. The two issues go hand-in-hand and cannot be separated. The debates will be moral and ethical in their scope; they also need to be realistic. Arguably, they should be international; as the solutions are not to be found within the health systems of small, individual countries.

(First published in the Scunthorpe Telegraph, Thursday 6th October 2011)