To the first part of your reply (who decided), my own preference is for informed paitent decision based on an independent review by a body such as NICE. I think that any patient offered therapy for which there exist real cost/value issues, should automatically be told about the pros and cons in plain English (and not by his/her prescribing physician who may be inadequately informed). Only with this objective pharmacological counselling should they then decide whether to pay for the drugs. This is going to be very tough of course, anyone in this position is probably in the worst situation of their life, and having to make such all-or-nothing decision on top will be horribly stressful.

About the second part of your comment:
I have worked in medical research for many years and I am firmly on the side of the drug companies. I am aware how much it costs to develop a new drug, and how many promising leads never make it. –However the problem of how, (or whether) to pay for very expensive therapies with limited efficacy doesn’t go away. It is only getting worse, and in the end could help bankrupt the system. Making this an ideological punch-bag is not the best way to go.

Second, while I accept that US Pharma is the biggest player, it is by no means the only one. The Europeans stack up very impressively, regardless of their health care systems. For example, Novartis: (Switzerland)., GlaxoSmithKline, (UK-based); Hoffmann–La Roche (Switzerland), AstraZeneca (Sweden), Bayer (Germany) etc.

Lastly, the way Avastin was approved for Breast cancer therapy has upset even Republicans. This is from the NY-Times article cited above (my emphasis):-
“The third approval for Avastin, for advanced breast cancer, came in February of this year. ..... The F.D.A. went against its own panel of outside experts, who had voted 5 to 4 against approval. The agency’s action has not sat well. Senator Charles E. Grassley, REPUBLICAN of Iowa, asked the Government Accountability Office to look into the F.D.A.’s approval of Avastin and some other drugs that “appear to have little to no effect in protecting lives and increasing health.”

The cost/value ratio of several of the new drugs is a problem which we, as a society must think through.