NICE’s position on the rule of rescue is incompatible with the purpose of the NHS as a state mandated healthcare system which must at least be the option of last resort for people where social values and preference would provide healthcare — despite NICE’s analysis. Government cannot let HTA bodies such as NICE ignore the rule of rescue. NICE argues that it adequately takes account of this — but there is a discontinuity in the applicable decision logic below and above NICE’s QALY threshold. NICE in effect is applying below the line logic to above the line issues. The issue of compliance and indeed civil disobedience may be applicable as doctors are prohibited from violating their professional codes of conduct, or acquiescing in acts or procedures that would cause them to violate their ethical code. A doctor strictly speaking cannot not aid a person caught by the NICE threshold cutoff, where they are able. The state is obligated to interevene and pay for expensive care as it is not an act of supererogation, but it is the State’s duty. Therefore, the State must act in cases above the line out of duty — aiding people who might cost a lot by HTA QALY benchmarks but if the state doesn’t act, and who will? This is especially troublesome in the UK where the NHS is presented as the health provider of last resort — not something NICE has clearly thought through. Will the politicians allow NICE to wag, so to speak, the objectives of universal healthcare?
As other countries adopt NICE-like thinking, how will they come to understand the role of the state?