Here in the US it’s pretty much a given that you will be required to foot at least some of the bill for your health care. To some people this arrangement isn’t just a matter of scare resources, it’s actually a feature of the system because it bring market pressure to bear on the system. It’s really just a question of how much people should be asked to pay.

Over in the UK, they’re having almost the exact opposite debate. The question there is: should people be allowed to put up their own money for medical treatment and still get help from the National Health Service. From a story in the New York Times:

Created 60 years ago as a cornerstone of the British welfare state, the National Health Service is devoted to the principle of free medical care for everyone. But recently it has been wrestling with a problem its founders never anticipated: how to handle patients with complex illnesses who want to pay for parts of their treatment while receiving the rest free from the health service.

Although the government is reluctant to discuss the issue, hopscotching back and forth between private and public care has long been standard here for those who can afford it. But a few recent cases have exposed fundamental contradictions between policy and practice in the system, and tested its founding philosophy to its very limits.

One such case was Debbie Hirsts. Her breast cancer had metastasized, and the health service would not provide her with Avastin, a drug that is widely used in the United States and Europe to keep such cancers at bay. So, with her oncologists support, she decided last year to try to pay the $120,000 cost herself, while continuing with the rest of her publicly financed treatment.

By December, she had raised $20,000 and was preparing to sell her house to raise more. But then the government, which had tacitly allowed such arrangements before, put its foot down. Mrs. Hirst heard the news from her doctor.

He looked at me and said: Im so sorry, Debbie. Ive had my wrists slapped from the people upstairs, and I can no longer offer you that service, Mrs. Hirst said in an interview.

I said, Where does that leave me? He said, If you pay for Avastin, youll have to pay for everything in other words, for all her cancer treatment, far more than she could afford.

Officials said that allowing Mrs. Hirst and others like her to pay for extra drugs to supplement government care would violate the philosophy of the health service by giving richer patients an unfair advantage over poorer ones.

Patients cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs, the health secretary, Alan Johnson, told Parliament.

That way lies the end of the founding principles of the N.H.S., Mr. Johnson said.

-Greg Dahlmann