The theme of euthanasia being debated again, from Lord Joffe's Assisted Dying for the Terminally Ill Bill to various Christians saying that very ill babies could be denied treatment.

The question of resourcing has come up, usually with fierce protestations that this debate has nothing to do with resourcing and that we would, of course, use whatever measures in our power to protect frail newborns and the elderly who have given so much to our society. Sadly, this is self-evident rubbish. Rationing decisions - and they are rationing decisions - are made all the time. The debate about herceptin's approval or otherwise from NICE is a case in point; are the benefits from this drug cost-effective?

Nor is this limited to state healthcare. HMOs in the US fall into the same category and have been protected since the 80s by Federal law from malpractice litigation on the grounds that the decisions regarding patient care are administrative rather than medical in nature. Ultimately, any form of private medical insurance is a bet that rations how many people will have access to a treatment based on their ability to pay.

If the world's population continues to grow and the people in the developing world aspire to something approaching Western standards of living, more of the world's GDP is going to have to go on healthcare, particularly if Tony Blair's heir apparent, Gordon Brown, continues his commitment to helping the third world.

Even if not, the desire for getting every last moment of life, regardless of cost, will mean that more money, whether through the state or not, has to be spent on healthcare. Even so, we will have rationing - deciding whether it is cost-effective to treat a particular person.

The rationing we have is not 'every person can have £n spent on them' or, even worse, 'you are worth spending £m on', but that we cannot afford the liability for a particular treatment across the NHS.

I find it distasteful that decisions like that have to be made, and even more so when a particular person's ability to pay comes into the equation. It is largely for that reason that I am very nervy about euthanasia; if we combine the acceptance of rationing with decisions about whether someone's life is worthwhile, we start approaching a set of conclusions that I feel few people would be happy with.

It is, perhaps, different with adult euthanasia - people can make the choice and we can, probably, set up systems so that there is no pressure on them from families, but the fears of whether this debate may lead are real. There is a need for a real debate on this; just how much are we willing to pay for healthcare?



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