Ethically permissible inequity in access to experimental therapies

Clinical ethics services are increasingly receiving case referrals regarding requests for access to experimental therapies. Sometimes, patients or families seek access to an experimental therapy that has not been subsidised by any government scheme, and for which no local clinical trial is underway. All else being equal, a patient may benefit from receiving an experimental therapy without making any other patient worse off. However, within public healthcare systems, treating only one patient with an experimental therapy, when others might also benefit from it, evokes a troubling sense of inequity. In this paper, I examine the relevance of Pareto principles and the ‘levelling down’ objection to ethical deliberation about patient or family-initiated requests for experimental therapies. While facilitating access to an experimental therapy may benefit a patient without making any other patients worse off, this does not dispel ethically relevant considerations concerning equity. When deliberating about cases involving inequity, clinicians and hospitals must balance directly improving the position of individual patients with avoiding contributing to or tolerating avoidable inequities. I argue that inequity in access to experimental therapies can be ethically permissible, but only if satisfies two conditions: firstly, the decision to provide one patient and not others with a promising experimental therapy must have a strong likelihood of contributing to future equity; and secondly, the inequity must be exercised in a way that shows respect for other patients who are not equally able to access the therapy in question.