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Entry 134, on 2005-02-22 at 14:30:57 (Rating 4, News)

How closely should rules be followed? Should we be controlled by strict rules with no exceptions or should there always be some flexibility? If there is flexibility, who decides on when it should be applied?

These questions were highlighted recently in a case where New Zealand's system of providing free pharmaceuticals probably caused a transplant to fail for a 15 year old boy. New Zealand's free pharmaceutical organisation, Pharmac, has a policy where a more expensive immune system inhibitor is replaced with a cheaper version one year after a transplant has been performed. In the current case the patient's condition has deteriorated and he only has 20% function in the transplanted kidney. Before the change of drug he was healthy.

The cheaper drug has been found to be adequate in trials on adults but there is no data for children. In Britain there is a guideline (not a strict rule) to use cheaper alternatives, but the clinicians ignore this and use the more expensive drug anyway.

So who is right? If the trials indicate the cheaper drug works, why do the doctors in the UK waste public money and use the expensive one anyway? And why have we in New Zealand wasted the opportunity of a successful transplant by trying to save a bit of money using a drug which seems to have caused these problems? Now the patient's deteriorating condition will end up costing the health system much more than continuing to use the better drug ever would. Plus there is the risk to the patient, who will probably need to go back to dialysis, and the distress of the kidney donor, who has made an incredible sacrifice seemingly for nothing.

In the end I believe the doctors in charge of the patient should make the ultimate decision. We shouldn't have bureaucrats in a regulatory organisation making decisions on someone's medical care. Guidelines are fine, but strict rules, which can't be changed aren't generally a good thing. I believe this applies everywhere. We shouldn't let rules and regulations get in the way of making the right decision, which can only be judged on a case by case basis.


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