Very expensive patients in a single-payer system

A single payer system for health care, such as the English National Health Service (NHS), must try to do as much good to as many patients as possible within the budget available. This utilitarian ethic has been operationalised by using cost-utility analyses. In the NHS a cut-off equivalent to about $50,000 per Quality-Adjusted Life-Year has become the norm. If implemented systematically, however, this ethic would deny treatment to groups of patients whose therapy is very expensive - $150,000 per year or more. We do treat these patients so a different ethic is implied. To identify this ethic, we may start with some modified Rawlsian principles of priority for the most disadvantaged in society, or look to communitarian principles of solidarity. Such principles require ethical behaviour from the pharmaceutical industry to avoid gaming on prices, although at present a pragmatic upper limit of price seems to have been established. We also need to explore the rules of when to apply utilitarian ethics and when the 'separate box' of alternative ethics is appropriate.