I thank Packer and Jampol for their critical reading of my editorial and Narayanan and Kupperman for their comments on the compassionate use of medications.1,2 They seem concerned that financial comparisons of drugs were not adequately addressed. Certainly, I would not exclude the cost of medication (or other interventions) to the patient from the matrix of considerations that influence treatment recommendations, but it remains true that the physician's primary obligation is to offer the most effective treatment based on his or her understanding of the best available evidence. The rationing of drugs whether by a group practice or a private or state health care plan sometimes creates conflicts with the best scientifically based recommendations. Naturally, this is a complex problem and the financial implications for a particular drug in a given patient will vary according to the clinical indication by payer and across state and country borders.
Miller JW. An Ethical View of the Ranibizumab and Bevacizumab Controversy—Reply. Arch Ophthalmol. 2008;126(2):286-287. doi:10.1001/archophthalmol.2007.37