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Well, now to Britain, where people rarely see a medical bill. They pay for health care through their taxes, and the government pays the doctors and the hospitals. Spending on health care per person is half of what it is in the U.S. costs are kept down through rationing. Often, the decision by the government not to pay comes in cases such as cancer in which an expensive drug offers the hope of a few extra weeks to live.

NPR's Joanne Silberner visited Britain and has this story on health care rationing through the eyes of a cancer patient and his doctor.

JOANNE SILBERNER: In his spotlessly clean home in Cardiff, Wales, Donald Sutherland is in the midst of constructing an elaborate model railroad complete with Scottish village. A tiny seven-car train races past.

Mr. DONALD SUTHERLAND (Insurance Broker, Wales): That one is a model of one I actually helped to restore.

SILBERNER: He jokes he'll be finished in 25 years. Such a long-term project wasn't in his plans 13 years ago. At age 41, insurance broker Donald Sutherland was diagnosed with a particularly nasty form of lung cancer. A Scotsman of few words, he raises his red eyebrows as he tries to describe it.

Ms. SUTHERLAND: It's a real gob-smacking experience when you get told that you've got malignant lung cancer. And when it was diagnosed, they gave me three months to live.

SILBERNER: Three months seemed hopeless. Sutherland got his affairs in order. One thing he didn't worry about was paying for his treatment. It was financed by tax revenues. He paid no bills. He started right away at the comprehensive cancer center near his home.

Mr. SUTHERLAND: I had two full courses of chemotherapy. I had three courses of radiotherapy in my chest and on my head because I had a brain tumor removed, which was a secondary tumor from the lung cancer.

SILBERNER: For reasons not even his oncologist can explain, Sutherland is still alive 13 years later. If Sutherland's lung cancer goes on the attack again, there's a new, very expensive drug available, Tarceva. Now, this drug won't cure the type of cancer Sutherland has, but it can extend life, according to one study, by an average of a couple of months.

If he wanted Tarceva, he'd have to pay the several-thousand-dollars-a-month cost himself. The National Health Service won't pay for it because it hasn't proven to be effective enough for his type of lung cancer. In the U.S., people can get it with the help of insurance or charity, but some people have gone broke. The cost of the drug just isn't worth it to Sutherland.

Mr. SUTHERLAND: If I was going to die in the near future, and in the meantime, I was going to bankrupt my wife because we need to get money together for treatment, I wouldn't have the treatment.

SILBERNER: Not even if you thought it might extend your life a month or two months or three months?

Mr. SUTHERLAND: Is that any great thing?

SILBERNER: This is where the medical cultures of the U.S. and the U.K. split. In the U.S., there's a strong tendency for doctors and patients to pursue even the smallest hope. But Brits like Sutherland and his oncologist, Fergus Macbeth, see it differently. Macbeth says he doesn't think Tarceva offers much hope to people with lung cancer like Sutherland's.

Dr. FERGUS MACBETH (Oncologist): From the evidence that I've seen, it is effective for a few patients, but not for many. And the average benefit in terms of improvement in mean survival is a matter of a few months. And it has got significant toxicity - not as bad as some chemotherapy, but you don't have nontrivial toxicity for some patients.

SILBERNER: That toxicity includes diarrhea, vomiting and rashes and the risk of serious liver and lung problems. He has other things to offer his patients: other drugs, the knowledge that cancer is unpredictable, and simple, good doctoring.

Dr. MACBETH: I think there's a huge role that we have, which is beyond just giving them the treatment. It's about managing their pain and managing their symptoms, managing them psychologically as best we can, and managing their family as well.

SILBERNER: Macbeth doesn't want to inflate his patients' hopes, something he sees happening in the U.S.

Dr. MACBETH: What to me seems to be a culture of gross overtreatment of patients, of raising false hopes and putting patients through extreme treatments for very modest gains or very modest probability of gains.

SILBERNER: The man in charge of saying yes or no is Sir Michael Rawlins. He heads a government agency, the National Institute for Health and Clinical Excellence. The agency decides for the NHS whether new and expensive drugs are worth the cost. Rawlins knows his agency can disappoint.

Sir MICHAEL RAWLINS (Chairman, National Institute for Health and Clinical Excellence): People who've got a lethal illness and want a drug that'll - they think will cure it, you know, want it now.

SILBERNER: But denying the chance of a few extra weeks or months - I asked him, isn't that taking hope away?

Sir RAWLINS: Yes. I mean, in some ways, that's true. And for people with life-threatening diseases, hope can be very important. And as a physician myself, I know that, I understand it. It's - but the truth of the matter is, we just can't do it any longer.

SILBERNER: Can't do it any longer because paying huge amounts of money for every new drug with the faintest hope of extending life even a little would make it impossible for the NHS to provide universal care. And Rawlins is sure that some day, Americans will have to deal more directly with these same thorny questions of rationing and the high price of hope.

Sir RAWLINS: You will, one day, have to take cost effectiveness into account. There is no doubt about it at all. You cannot keep on increasing your health care costs at the rate you are for so poor return. You are 29th in the world in life expectancy. You pay almost twice as much on health care per person as anyone else in God's Earth.

SILBERNER: And there are millions of Americans with no access to routine health care. This is the tradeoff that the U.K. has made, rationing care so that everyone is covered.

Sir RAWLINS: And we have, in Britain, as in most of Europe, actually, had health care systems that, based on the principle of social solidarity, that we look after each other in time when we're sick. And that's very precious, actually, to us. And I think that's what we find so difficult to understand about your health care system. You don't have that.

SILBERNER: Cancer patient Donald Sutherland is satisfied with the British system, even with its limits.

Mr. SUTHERLAND: I think we're quite patient people, albeit that, you know, if we want something, we will make sure that we get it. And I think, by and large, that in my experience, I can only say that whenever I've needed the National Health Service, it's always been there, and I've always had first-class treatment.

SILBERNER: He says he doesn't expect his fellow taxpayers to pay for a drug unless there's solid proof that there's a benefit.

Mr. SUTHERLAND: You have to be realistic about this. You know, the demands are infinite but, you know, the resources are finite, and you just have to accept it.

SILBERNER: A concept that Americans have resisted.

Joanne Silberner, NPR News.

SIEGEL: Massachusetts is the only state that requires everyone to have health insurance coverage. You can learn how that's working out in a video report at npr.org.

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