Letter: Viagra rationed

Sir: Doctors have been part of an implicit rationing process since the NHS began, and the British Medical Association has been eager to involve the public and the Government in a debate about explicit rationing for years. What we have never done - as your leading article of 23 January misleadingly alleges - is to supply drugs "to everyone who thinks they may need" them. As you rightly suppose, this would bankrupt the NHS.

The main premise of your attack on the BMA for encouraging the prescription of Viagra on the NHS is that we are "selfish and irresponsible" trade unionists whom you compare to "the worst of the flying pickets". On the contrary, family doctors have had to be very careful about all their costs, as they are well aware of the financial limitations of the NHS. Regulations compel us to prescribe any drug which is licensed, has not been restricted by "blacklisting" or "greylisting", and which in our clinical opinion the patient needs. To call that "gesture politics" is ludicrous. We are not there to pander to patients' wants, or to provide recreational drugs. We have to relieve suffering and distress, whether life-threatening and painful or not. In this regard, impotence is no different from any other illness.

Frank Dobson has been brave in taking personal responsibility for rationing, and we welcome this. Unfortunately, he has chosen to do so arbitrarily by producing a list of "worthy" causes of impotence. The excluded patients, such as those whose impotence is associated with heart, lung, liver or kidney disease, will be forced to buy Viagra privately. There is no evidence behind these distinctions. What makes an impotent diabetic "better" than an impotent man with kidney failure?

The guidelines do not allow discretion. They are cruel and arbitrary. Mr Dobson implies that the NHS is primarily intended for patients with life-threatening or painful conditions. What about the blind, the deaf and those with skin disease? Clearly, the public and the Government must now, at last, become involved in a lengthy and thoughtful debate about whether the NHS should have more resources or needs to ration services more explicitly. Although we would favour the former, the reality is that the latter is the only credible solution. The debate must include a rational consideration of need, clinical effectiveness, cost-effectiveness, equity and social values - matters virtually ignored in Mr Dobson's proposals.

Dr JOHN CHISHOLM

Chairman

General Practitioners Committee

British Medical Association

London WC1