New treatments: costs, benefits and decision-making procedures.

One hallmark of modern medicine is the ever-rising cost of providing life-saving or life-extending treatments. Advances in medical care and the ability to improve the duration and quality of life, combined with the expectations of both doctors and patients that all new modalities of treatment developed will be implemented in everyday practice, are the major reasons for modern medicine's becoming so expensive. In these circumstances resource allocation decisions need to be made and appropriate priority-setting processes developed. This challenge faces all societies but most agonisingly middle-income countries like South Africa where the expectations of physicians and patients are geared to the best that can be achieved in any country — even the wealthiest. Expensive, new or established standard treatments that may benefit patients may be considered in at least two categories. The first is when each individual patient will be a direct beneficiary. This applies, for example, when a pacemaker or orthopaedic prosthesis is installed, when an organ such as a kidney, heart or liver is transplanted, or when chronic renal dialysis is initiated. While such treatments have some mortality and a measure of sub-optimal results, good outcomes are the rule. The second category is when an expensive new or standard treatment is used to achieve a statistically demonstrable benefit for a patient population. A characteristic feature of such treatments is that many patients must be treated to save one life or prevent one adverse event. Most often it is not possible to determine in advance, or even retrospectively, to which patients the benefits accrue. Examples include new drugs for malignant disease and for such chronic diseases as rheumatoid arthritis, hyperlipidaemia, hypertension and coronary vascular disease. The new drug described by Richards and colleagues (p. 416) for reducing the mortality rate from severe sepsis is another example. In the case of drotrecogin alfa (Xigris), 16 patients with severe sepsis must be treated at a cost of R55 000 each to save one life. Thus it would cost R880 000 to save the life of one unidentifiable person. Consider the dilemma posed for a public hospital or medical aid scheme faced with this choice. On the one hand clinicians seek increased budgets for renal dialysis, pacemaker insertions and hip prostheses. For example, nephrologists argue that it is possible to prolong the life of one identifiable patient by renal dialysis for about R60 000 a year (in the public sector). Moreover, each …