Tough choices?

In “Tough choices: private sale of drugs in public hospitals,”¹ the authors base their argumentation on a sleight-of-pen by using the concept of “medical necessity” or lack thereof. The absurdity of the medical necessity argument is readily apparent from the discrepancy in the access to cancer drugs across Canadian provinces. Could anyone argue rationally that alemtuzumab is “medically necessary” in British Columbia or Manitoba but not in Ontario or Quebec? Can the state deny a patient a beneficial service, if the residual cost-utility falls below the customary threshold because a patient bears its major cost? The answer to this conundrum lies not in the blunt instrument of new legislation spawned by ideology, but in carefully individualized decision processes that involve all the major stakeholders.