Political decisions influencing medical treatment when scientists say it's not a good idea
In New Zealand, a group of cardiac specialists finds itself silenced not by lack of evidence, but by institutional interpretation of political will. The dispute over three diabetes medications has surfaced a deeper tension: whether targeting treatment toward populations with documented biological and epidemiological risk constitutes sound clinical practice or impermissible racial reasoning. Health NZ's refusal to allow the Cardiac Network to formally object to Pharmac's proposed changes reveals how a Cabinet directive meant to ensure fairness may, in practice, constrain the very expertise meant to guide it.
- Pharmac proposes expanding access to three diabetes drugs by removing ethnicity-based eligibility — a move framed as broadening equity but contested by specialists who say it dismantles evidence-based targeting.
- The Cardiac Network, armed with clinical data showing Māori and Pasifika face disproportionately higher diabetes risk, wanted to formally object — but Health NZ blocked the submission, citing a September 2024 Cabinet directive against race-based service allocation.
- Individual clinicians may still submit personal objections, but the institutional voice of the Cardiac Network has been effectively silenced, creating a gap between collective medical expertise and formal policy input.
- The lead cardiologist argues Health NZ has over-interpreted the directive, drawing a pointed analogy: directing melanoma treatment toward fair-skinned patients is biology, not ideology — and the same logic applies here.
- Pharmac has yet to rule, and the outcome will hinge on whether clinical evidence of health disparity can be disentangled from the ethnicity-based framing the government has declared off-limits.
A group of cardiac specialists in New Zealand wanted to formally object to a government drug-funding proposal — and found they were not permitted to. The dispute involves three diabetes medications, and whether access to them should account for ethnicity as a clinical factor.
Pharmac, the public medicines-funding agency, proposes lowering the clinical threshold for heart disease risk and removing ethnicity-based eligibility criteria entirely. The agency estimates this would extend treatment to roughly 23,000 additional people annually over five years — an expansion that sounds straightforwardly positive.
The Cardiac Network disagrees with the framing. Its specialists argue that Māori and Pasifika populations carry substantially higher rates of diabetes and its complications, independent of income or circumstance, and that directing expensive therapies toward the highest-risk groups produces the greatest health return per dollar. Outgoing Cardiac Society chair Martin Stiles put it plainly: the clinical evidence points to a clear target, and ignoring it wastes both money and lives.
But Health NZ told the Cardiac Network it could not file an institutional submission making that case. Senior officials interpreted a Cabinet directive from September 2024 — which stated that public services should be prioritized by need, not race — as prohibiting ethnicity-based clinical reasoning in formal submissions. Individual clinicians remain free to submit personal objections; the Network as a body does not.
Stiles believes the directive has been misread, and that Health NZ is conflating a broad policy statement with a prohibition on clinical science. He compared the situation to targeting melanoma treatments at fair-skinned patients — a biological judgment, not an ideological one. The government routinely directs resources where need is greatest, he noted; the Cardiac Network had simply identified where that need lies.
Health NZ declined to be interviewed, issuing only a brief statement noting that Pharmac had received feedback from multiple clinical networks. Pharmac has not yet ruled. The decision will ultimately test whether evidence of health disparity and ethnicity-based allocation can be treated as separate things — or whether, under the current political framework, they cannot.
A group of cardiac specialists within New Zealand's health system finds itself in an unusual bind: they want to object to a government drug-funding decision, but their employer says they cannot. The dispute centers on three diabetes medications—empagliflozin, dulaglutide, and liraglutide—and whether access to them should be allocated partly on the basis of ethnicity.
Pharmac, the government agency that decides which medicines get public funding, is proposing to broaden who can receive these drugs. The plan would lower the clinical threshold for heart disease risk and remove ethnicity-based eligibility criteria entirely. The agency estimates the change would allow roughly 23,000 additional people per year to access treatment within the next five years. On the surface, this sounds like expansion—more people helped, more equitable access.
But the Cardiac Network, a group of specialist clinicians working within Health NZ, sees it differently. They argue that the evidence is clear: Māori and Pasifika populations face substantially higher rates of diabetes and its complications, independent of income or social circumstances. When funding is tight, as it always is in public health, they contend that targeting expensive new therapies to the groups at greatest risk produces the maximum health benefit per dollar spent. Martin Stiles, the outgoing chair of the Cardiac Society and a member of the Cardiac Network, put it plainly: clinical data shows that directing these medications toward Māori and Pacific Island New Zealanders yields the best outcomes for the money invested.
The real friction, though, is not about the science. It is about what Health NZ says the Cardiac Network is allowed to say. The specialists wanted to file a formal submission with Pharmac objecting to the removal of ethnicity criteria. Health NZ declined to permit it. Senior officials at the organization interpreted a Cabinet directive—issued in September 2024—as prohibiting submissions that rest on ethnicity-based reasoning. That directive stated the government's expectation that public services should be prioritized on the basis of need, not race, and cited international conventions against racial discrimination.
Stiles believes Health NZ has misread the directive. He suggested the organization may be over-interpreting what was meant as a broad policy statement. The distinction matters: individual clinicians can submit their own objections, but the Cardiac Network as an institutional body cannot. It is a subtle but significant constraint on how medical expertise can be formally presented to decision-makers.
Stiles framed the issue as one of scientific integrity being overridden by political interpretation. He drew a parallel to targeting melanoma treatments at fair-skinned people—a medical decision rooted in biology, not ideology. The government, he noted, regularly directs resources to where they are most needed, whether in roads, justice, or health. The Cardiac Network had identified exactly such a target: a population at disproportionate risk, where expensive treatment dollars would do the most good. Yet the government's response, as filtered through Health NZ's reading of the Cabinet directive, was to say that reasoning cannot be submitted because it is race-based.
Health NZ declined to be interviewed but issued a statement acknowledging that Pharmac had received feedback from multiple clinical networks, including those focused on eye health, renal disease, and diabetes. The organization said it looked forward to Pharmac's decision once all submissions had been considered. Pharmac itself has not yet ruled. What happens next will likely turn on how the agency weighs clinical evidence of health disparities against the government's stated preference for need-based rather than ethnicity-based allocation—and whether those two things can, in fact, be separated.
Citas Notables
When resource is limited, maximum benefit is gained when you target therapies to New Zealanders most at risk of disease and disease complications.— Martin Stiles, outgoing chair of the Cardiac Society
Political decisions have been made that are influencing medical treatment, when scientists and clinicians at the coalface of New Zealand medicine are saying this is not a good idea.— Martin Stiles
La Conversación del Hearth Otra perspectiva de la historia
Why does removing ethnicity from the criteria feel like a threat to these doctors?
Because they have data showing Māori and Pasifika people get diabetes at much higher rates and face worse outcomes. If you take ethnicity out of the funding rules, those groups don't automatically disappear from the system—but the targeted investment does. The doctors see that as leaving money on the table in terms of health impact.
But isn't the Cabinet directive saying we shouldn't make decisions based on race at all?
That's the tension. The directive says prioritize need, not race. But the Cardiac Network is arguing that ethnicity is a proxy for need here—these populations have documented, higher clinical need. The question is whether you can acknowledge that without violating the spirit of the directive.
So why is Health NZ preventing them from even making the argument?
They're interpreting the directive as a hard line: no submissions to Pharmac that rest on ethnicity-based reasoning. It's a cautious reading, maybe overly cautious. Individual doctors can speak up, but the institution cannot.
What's the practical difference?
Institutional weight. A formal submission from the Cardiac Network carries more authority than scattered individual comments. It signals that this is not one doctor's opinion but the consensus of specialists in the field.
And if Pharmac removes the ethnicity criteria, what actually changes for patients?
Theoretically, more people overall get access. But the specialists worry that without targeted outreach and without ethnicity as a criterion, Māori and Pasifika patients may not reach the clinic in the same numbers, or may not be identified as candidates. The expansion might not reach the people who need it most.
Is this a fight about equity or about resources?
Both. It's about whether you can be equitable by being race-conscious, or whether equity means treating everyone the same. The doctors think the data supports the first view. The government directive seems to lean toward the second.