Can you tell a siren from a tocsin?

There are two voices in this room. One says, “Just at this point in time, I feel that life has sufficient interest for me to keep going, full bore, whatever it may cost”. The other replies, “There will come a time, if I am allowed to make a choice, that I may change my mind and say ‘just let me drift off into the aether’”.

As one ages, this internal exchange of voices becomes more frequent. It defines the dilemmas that surround the cost of the health system, the shape of which is increasingly connected to an assortment of individual expectations.

Children are precious commodities, and the almost infinite amount of money spent to save a child will go unquestioned. It is only when you are an adult that these expectations of immortality become confounded. After about the age of 40, it increasingly becomes a matter of choosing one of the options portrayed by the two voices.

In the end, it is about having “a good death”. Just as one wants a full and disease-free life — mental faculties intact, free of pain, able to see and hear and able to move about freely — one also wants a good death.

At conception, everyone receives a genetic card from their ancestors. Increasingly, the value of that card can be measured as it is decoded, and in the future you may be able to trade your card in for a better one — at a cost. In the meantime, you have to be careful with your card; you do not want to drop it where it might be damaged. Even if you look after it, the card itself may change — the name of this game is “mutation”.

The older you get, the more frequently you check the condition of your card. My aged companion, the second voice in my head, has begun seeking information. “Can I get my card repaired by someone with appropriate expertise or can I do it myself? Have I got enough information to make that choice, to work out the risks of having the card fixed or leaving it as it is?”

The promise of an elixir of life delivering the Holy Grail of immortality is constantly before us, but it is a false promise.

The recent addition to the Pharmaceutical Benefits Scheme (PBS) of the drug ipilimumab (Yervoy; Bristol-Myers Squibb) for the treatment of advanced metastatic melanoma is a case in point. Each treatment previously costing the patient $120 0001 can now be accessed for $36 through the PBS. Like everybody else, I can read what Wikipedia says about this drug that helps T cells knock off the cancer — it appears to be effective, at least for a while. It seems that the drug can extend life, although not by much when measured against the expected three score and 10 years. A casual comment by an oncologist suggests that cancer drugs constitute only six per cent of the national health bill,2 but what are we really getting — a median increase in life expectancy of 12 months?

Before its listing on the PBS, a news story about ipilimumab opened with the headline “Melanoma wonder drug Yervoy out of reach for most Australians”.1 But the article’s last sentence said that “the drug has serious side effects with some patients dying from toxicity or bowel perforations”. Reverse the message and the headline reads “New drug dogged by reports of toxicity”, with the last sentence concluding that the “so-called wonder drug disappoints in its ability to extend life”. That last sentence worries me because I want a pain-free environment; I want to keep enjoying myself — and then, when the time comes, just let me go. Those are the odds I am really interested in — buying the time, but only if it is worth it. I do not like the prospect of getting any of those ghastly complications. It is all about mitigation of that risk.

How much expenditure will be incurred before there is acceptance that the time has come; when the first voice fades and only the second voice remains? This encapsulates the dilemma of health system costs, especially when it is one’s own health under consideration. My family and doctors may be struggling to make me believe that the first voice is not fading. Connect that well of emotion to the media pipeline and who can resist the lure of continuing to search for the Holy Grail?

However, when divorced from any emotional commitment, I can pontificate about the escalating cost of the health system. When the two-by-two box of outcome versus cost is considered in an objective manner, the “best outcome at least cost” solution always wins. The problem is that health is personal and the arguments swirling around cost-effectiveness are not. Should “Health: the language and its meaning” be inserted into the school curriculum? But with youth comes the perception of living forever, so when some young person does not, there is an outpouring of emotion. Inserting objectivity into these debates is difficult at any age.

It comes back to balancing maturity and insight, our personal and emotional decisions, and the capacity to recognise, as a group, that our responsibility lies in satisfying those emotions while always remembering that cost and effectiveness are part of our clinical acumen. It is a theme that will always underpin any pivotal moment when individuals, their families and their health professionals hear, but ignore, the second voice. There are two voices in the room, and when drugs like ipilimumab come calling, remember how Ulysses dealt with the enchantment of the sirens. Not with a tocsin.