In 2008, the first whole cancer genome was sequenced, and in 2022, the entire human genome (the remaining 8 per cent) was revealed, leaving no gaps. These two monumental scientific advancements clearly signpost the direction in which oncology is headed: personalised medicine, tailored down to the DNA of each patient.
The potential for precision cancer treatments is almost infinite and could hold the key to transforming how we combat a disease that takes approximately 167,000 lives each year. However, these new treatments could also undo the logic on which the NHS was built. The NHS assumes that patients with the same disease should get roughly the same treatment. Personalised medicine assumes the opposite.
This creates a problem that no political party wants to address: If healthcare becomes personalised, both access and cost become political fault lines.
A Healthcare Revolution
The idea that treatment depends on a person’s needs rather than their bank balance is central to the moral identity of the NHS. Politicians love this idea of universalism because it’s simple, safe and appealing to the electorate. But the onset of personalised healthcare undermines the idea of a one-size-fits-all model, as well as the general notion of free healthcare for all.
If two people have the same illness but require completely different treatments (with vastly different associated costs), then equal access no longer means offering everyone the same treatment. It means offering everyone exactly what their biology demands, irrespective of cost.
This sounds noble, but given the present state of the NHS rather unattainable. There is an immense moral dilemma here. It should be self-evident that some people will require far more expensive care than others to achieve the same outcome, and the NHS will have to decide whether it pays for it or not.
What is a Life Worth?
The NHS rarely faces this question directly, but personalised medicine makes it unavoidable. Some precision cancer treatments, such as CAR T-Cell therapy, cost hundreds of thousands per course for a single patient. What happens when hundreds of these treatments become available to dozens of patients? Does the NHS spend enormous sums treating small numbers of people, potentially taking away from budgets for treating other diseases? Should it cap spending per patient? None of these questions fit easily into anyone’s ethical comfort zone.
For those on the left of the political spectrum, it poses an almost paradoxical question of how universalism and fairness can be maintained when the treatments are unequal in nature.
And for the right, it raises complex issues about what a minimal state could look like when people expect that state to fund cutting-edge, individualised treatments.
The Risk of a Two-Tier Future
If politics ignores this shift, inequality will widen to unfathomable levels. This is already happening, as evidenced by the growing demand for private healthcare, currently valued at £13.8 billion. We’re looking at a future where some patients will have access to advanced care, whilst others won’t, and this future is already on our doorstep.
Those who can afford private clinics will seek faster testing and the latest treatments. Those who live near major NHS centres may benefit from early adoption of individualised healthcare. But those living in underfunded regions will just have to wait, maybe forever. These national and regional disparities will result not from a lack of scientific research or the desire to modernise, but from the financial and logistical difficulties of introducing innovative technologies and training specialist staff.
The socio-political implications of the above scenario go beyond healthcare. Should the upper classes have access to treatments unavailable to the less fortunate, we could witness the rise of a new ‘ultra-elite’ class. If the supremely wealthy can already disproportionately affect elections with huge spending power, imagine a world where they can literally live longer and be healthier than the common lot. This would give the ultra-elite enough time to participate in more elections, grow and maintain their electoral size, and gain a louder voice.
A Debate Not Yet Had
As Martin Luther King Jr put it, ‘there is nothing more tragic than to sleep through a revolution.’
It should be clear by now that no party gains votes by discussing something so profoundly divisive as personalised healthcare. Forcing politicians to decide which treatments the taxpayer should fund, and how to ensure there is enough of them to go round, is a messy and complicated business.
But the longer the political class dances around the conversation, the closer we get to these inequalities becoming entrenched. Avoiding the conversation is like refusing to read a map because you’re scared of the terrain. But the reality is there regardless, and it’s up to us to create a clear path towards it, for everyone.
To Infinity and Beyond?
Fortunately, precision treatments are advancing at an astonishing rate and creating unprecedented change. Unfortunately, Westminster is not keeping up. This sluggishness is arguably not the result of indifference or incompetence, but of an inability to see past one’s own party’s precarious success and the needs of the next election. This political short-sightedness, which is set to have a lasting social impact, is really nothing but pusillanimity — a characteristic of quite a few recent politicians.
If Westminster continues to pretend that the NHS can adjust to the shift in healthcare without confronting the obstacles, Britain will soon find itself in a system where equality is promised but no longer delivered.
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