Jeremy
Thanks for your reply which also made several different points. If I have
understood correctly you are really raising three issues:- pragmatic issues
about diagnosis and dosage frequency, rationing issues about the way in
which priorities are established, and cost issues as this is undoubtedly an
expensive drug.
1) Pragmatic issues about diagnosis and dosage.
I'm not an andrologist but if someone is impotent and Viagra cures it
that's good enough for my GP point of view. Psychological impotence is
probably just as damaging as physically caused impotence and as you rightly
say increasingly there is an overlap with physical causes being found for
impotence previously considered psychological. My only intention in
stating medical need was to exclude recreational use. The diagnosis of
impotence is not necessarily easy, but neither is the diagnosis of backache
with access to £1000s pounds worth of benefits, early retirement etc.
Dosage - been debated on this list. In fact most patients and their
partners would probably settle for a relatively modest re-establishment of
their sex life. There are national averages for coital frequency and I
could stand behind a view that said the NHS isn't here to turn people into
supermen.
2) Rationing issues about the way in which priorities are established.
Firstly your post suggests that capacity to work should influence the
treatment a patient would receive. Do you really mean this? Would you
fail to put back the severed arm of a 55 year old otherwise fit divorced
man U/E for 10 years who will probably never work again? There are
arguments for this point of view. However in the UK they have generally
been found totally unacceptable and tend to get raised only when debating
access to treatment for sexual problems and infertility when some doctors
and others seem to suddenly find them useful.
Secondly your post tries to compare the priority of impotence treatment
with a few issues which you obviously consider at the top of the NHS
priority list. This is not the point. To exclude Viagra on this basis you
have to show that it is less important than the lowest priority treatment
that the NHS does give. Lots of examples have already been given and I
don't think the anti-Viagra lobby can go on using the high priority
treatments in their arguments.
Thirdly you implicate the patient viewpoint. "How could I explain to my
arthritis patients that they will have to wait longer.... They have been
in my surgery in tears...." I think you might be surprised by some
patients' responses. If you have any 60 year old impotent arthritics try
asking New hip and no Viagra, cheap arthroplasty to cure pain and Viagra
for life? In any case I wonder on what ethical basis you feel that the
(presumed) psychological pain of impotence is less worthy of treatment that
the psychological pain of depression or the physical pain of arthritis.
Both are tolerated to a surprising degree by some individuals and
intolerable to others.
3) Cost.
I think we agree that the NHS cannot afford everything that patients want
or we would wish to offer. Once we establish a way of setting priorities
we can draw a line. If cost is integrated into the priority setting it
needs to be in a systematic and transparent way, not on an ad hoc or
prejudicial basis - isn't this both self evident and in everyone's best
interests?
Finally while Viagra may be a side issue I think this debate is almost
pivotally important to the future of our profession! If we are to
influence government and the wider public we need some shared understanding
of how or whether the NHS can cope with the increasing divergence between
resources and need / demand. The consensus doesn't need to be 100% but we
do need to get a lot closer than we (the profession) appear to be at the
moment.
JB
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