BMJ  2005;331 (5 November), doi:10.1136/bmj.331.7524.0-f

Editor's choice

Survival of the richest

My brother raised an ethical dilemma over lunch last week. Should he give his private patients a prescription for Tamiflu (oseltamivir) if they ask for one while his NHS patients don't have that option? At the time I didn't have an answer, but Michael Jefford and colleagues provide some help in this week's BMJ (p 1075). Although the principle of distributive justice suggests he shouldn't offer something to some patients that others can't have, two other principles guiding medical ethics—beneficence (acting in the patient's best interests) and respect for autonomy—dictate that he should. "Doctors should be committed to the individual patient's interests and autonomy rather than their own conception of social ideals such as equity," they say.

But Jefford and his colleagues are talking in the context of drugs for which the evidence is flimsy but supply is assured. Does their answer apply where supplies of a drug are limited? I would think not. Until Roche and GSK sublicense their neuraminidase inhibitors so that the world can scale up production (p 1041), letting some people pay to stash away supplies inevitably means others who may need the drug will be denied. When the pandemic comes it will be survival of the richest, red in tooth and claw.

The world could avoid this grim scenario by following Canada's lead. Roche Canada has stopped private sales of oseltamivir while the government builds up a supply to be given to those most in need (p 1041). The US by comparison presents an object lesson in how not to do it, demonstrating not so much distributive justice as distributive chaos. Walmart and other large retail chains have obtained large quantities of flu vaccine, leaving doctors unable to get hold of sufficient doses (News Extra)—another example, on top of last week's powerful personal view from Lori Smith in Tennessee, of how the market can't be trusted to act in the best interests of individuals or society. Among the rapid responses, Paul Clift says Smith's story highlights precisely why patients' and clinicians' organisations should be uniting to oppose any attempt to bring profit driven initiatives into the NHS.

Americans' lack of information about US health-care reforms may be partly to blame. Gary Schwitzer monitored health policy news coverage throughout the 2004 US election year on three award winning local television stations (p 1089). Despite there being an estimated 45 million Americans without health insurance, over this period the most watched newscasts carried only one story about the uninsured.

There will be flu this winter, and we must be prepared for a flu pandemic. Fleming gives clear and sobering advice to healthcare professionals (p 1066). Plan your response now, familiarise yourselves with the national plan, prepare to prioritise between patients, be ready to manage cases by phone, and do not be swayed by media hype. As for my brother, perhaps the most immediately useful advice in this week's BMJ comes from Jon Durnian (p 1069). Don't tell your builders you're a doctor: they'll just hike up the price. Now that's what I call distributive justice.