Economic Evaluation and Health Care Cost-effectiveness analysis

for treatments that "give rise to special concern." The secretary of state has chosen not to include goserelin in this category in the revised code of practice coming into effect on 1 November. Had she done so and chemical castration been recommended to Mr K as a treatment for mental disorder, legal recognition of special concern might have approximated such treatment to orchidectomy. But goserelin has not been included, and, furthermore, neither treatment option for Mr K is apparently directed to mental disorder. Goserelin is thus a far cry from invasive, irreversible orchidectomy. This only adds to the dilemma of patient and doctors alike. Application might be made for a judicial declaration that orchidectomy is lawful in this case. The casuistry of such litigation depends on medical opinion ofwhat is appropriate. The best interests approach is often taken without specifying which interests are the best or who decides.4 Despite its limitations the best interests approach is in any case better suited to decisions concerning treatment of incapable patients than it is to decisions denying treatment to a patient in full possession ofhis mental faculties.5 Legislation and case law offer analogies both for and against performing orchidectomy. The decision in the case of Mr K could be made by a judge, by an ethics committee, or simply from an informal second opinion. Mr K, however, might justifiably expect his problem to be resolved not by asking why his desired operation should be performed but rather by asking why it should not if his autonomy and desire not to reoffend are to be respected.