I was always a fan of fiction. As a young reader, one phrase lingered after a gruesome murder scene: the death rattle. I didn’t know exactly what it meant, but I understood its effect. It suggested something cold, frightening and deeply unpleasant.

A few decades later, I have a proper understanding. The term describes the distressing sound sometimes heard as a person approaches death, usually because secretions accumulate in the upper airways. It may not always trouble the dying person, but it can be profoundly upsetting for relatives at the bedside.

Modern palliative care eases not only the patient’s suffering, but also the distress of those close to them. Symptoms once associated with dying from a terminal illness need not be accepted as inevitable. That is why the withdrawal of injectable Buscopan from the Irish market should concern every pharmacist, clinician and policymaker.

For those involved in palliative care, Buscopan injection is a bog-standard drug. A few weeks ago, I was blindsided by news that it had been removed from the Irish market. Many palliative-care services that rely on it appeared equally unaware.

There is no indication that this was a safety or regulatory withdrawal. The product remains available elsewhere in Europe. It is difficult to pinpoint what exactly has led to this extraordinary state of affairs, although I am open to suggestions.

That is what makes it so infuriating. A commonly used palliative-care medicine has vanished, with little meaningful warning to frontline professionals. The question also arises of who knew what, and when? But we won’t go there today.

Yes, an alternative exists in glycopyrronium. But anyone who has lived through shortages will recognise the pattern. Demand shifts to the substitute, supplies tighten, and soon we may hear that it is unavailable ‘due to an unexpected increase in demand’. It is also more expensive.

It reflects a problem the State has known about, but ignored, for years. As reimbursement prices for older, cheaper medicines are pushed ever lower, it becomes harder to justify supplying them into a small market such as Ireland. Eventually, manufacturers reach the point at which it makes more commercial sense to label a medicine ‘not marketed in Ireland’ than to continue selling it at an uneconomic price.

Every pharmacist understands the consequences: frustrated patients, uncertain prescribers, extra administrative work, and time spent sourcing alternatives, explaining shortages and trying to organise special procurement workarounds. The pattern has become predictable.

As I write, another staple has disappeared: Chloromycetin eye drops. Ironically, they were the only antibiotic eye drops available under the Common Conditions Service, because the alternative, Fucithalmic, has itself been unavailable for years. Again, this was neither a safety nor regulatory issue. It appears to be another commercial withdrawal.

Nobody disputes that managing the national medicines budget is difficult. But there comes a point at which aggressive cost control becomes a false economy.

There is a law of diminishing returns in squeezing reimbursement for inexpensive, older medicines. Save a little more at one end and, eventually, the product disappears altogether. The health service is then left relying on more expensive alternatives, unlicensed imports, hospital procurement workarounds and discretionary reimbursement schemes. Continuity of supply, formulation, quality assurance and clinical familiarity can suffer. The supposed saving quickly becomes illusory.

Patients with limited means can be left unable to access medicines that should be routinely available. Medical-card patients may face a cruel choice: pay privately for treatment they cannot afford or enter the hardship lottery and hope discretionary HSE funding is approved. That is not equitable access to healthcare. It is a system in which availability increasingly depends on income, persistence and luck.

Most pharmacists could recite a long list of medicines that have quietly disappeared from the Irish market. Each withdrawal may be explained away. Taken together, however, they point to a system failing to protect the supply of essential, low-cost medicines.

Oscar Wilde described a cynic as someone who knows the cost of everything and the value of nothing. That phrase feels especially relevant now.

The State must consider more than a medicine’s unit price when setting reimbursement. It must account for continuity of supply, the cost of alternatives, the burden on healthcare professionals, the impact on patients and the principle of fair access to treatment.

It is not good enough to drive down prices until companies would rather leave the Irish market than continue supplying essential medicines. Nor is it acceptable to claim savings when those medicines are replaced by costlier, less reliable or unlicensed alternatives.

I believe that the withdrawal of injectable Buscopan is a stark example of what happens when the state fails to appreciate the value of medicines. This is not merely a procurement problem. It is a question of dignity in dying, fairness in treatment and whether medicines policy serves patients before spreadsheets.

Will anyone learn the lesson?

For your information, since the time of writing, the PCRS have issued a Buscopan Injections Temporary Code.