How do you put a monetary value on someone's life? When resources are finite, patients" needs are great and drugs are expensive, how do you decide what to prescribe to achieve the most cost-effective results?
NICE, the National Institute of Clinical Excellence, was set up in the UK specifically to lay down guidelines on issues like this. Yet NICE, it seems, can't do right for doing wrong.
Last month it issued its final guidance recommending Roche's Herceptin (trastuzumab) for early breast cancer while with almost the same breath rejecting the same manufacturer's colorectal cancer drug Avastin (bevacizumab) together with Merck's Erbitux (cetuximab).
The UK media usually paints NICE as the hard-hearted villain of the piece - prevaricating over its decisions while denying life-saving treatment to mothers of young children, devoted husbands, loving parents. Yet diseases like cancer do not discriminate on grounds of class, wealth, education or family circumstances and it is left to bodies like NICE to make an independent assessment of how limited resources can best be deployed.
Erbitux and Avastin were not rejected on the basis that they are not efficacious, but because neither had made a convincing cost-effectiveness case. NICE's calculations suggested that Erbitux cost e48,500 per quality adjusted life year (QALY), well above the e29,400 threshold below which NICE would tend to approve a drug automatically.
Predictably, the "cruel" and "scandalous" decision was greeted with anger by several UK cancer charities, which blamed the high prices charged by pharmaceutical companies and Government pricing policy for preventing the drugs being freely prescribed. It has even been suggested that NICE may be a victim of its own success - by saying "yes" too much, it has added to the financial pressure facing the UK health service.
In an age when financial resources are scarce and the latest treatments are increasingly complex and expensive, NICE is in an invidious position. Every decision is a death sentence for some and a reprieve for others, but as a NICE spokesman said, "there is a finite amount of revenue and this process has to be done".
Whether you are a patient denied a potentially life-lengthening treatment or a pharmaceutical manufacturer whose latest drug is being denied access to a lucrative market, such decisions are hard to accept.
Just be thankful you're not the one having to make them.