Archives for posts with tag: public health


Great first class yesterday at the Berman Institute in my new course, Ethics of Healthcare Decision Making. What is needed for a decision? What are the goals? More to come on these topics, and our fascinating discussions.

Less than one month before publication of Talking To Your Doctor! Here’s another trailer with a new take on the importance of doctor-patient communication.

Peruse this letter which a woman of my acquaintance (okay, my wife) recently received. Note the importuning “annual mammogram”

and the official-sounding “According to the American Cancer Society…” (let’s not mention the U.S. Preventive Services Task Force, which recommends every two years, and only for women over 50), juxtaposed with the wishy-washy “Please contact your physician to see if it is appropriate.” Which is it? Does the recipient need an annual, or does she need to talk to her physician? Perhaps it would be better to do one or the other: either recommend in the letter straight out, or let her talk the matter over with her doctor?

Here we have (a) fragmentation of care and advice (different opinions from across the spectrum); (b) confusing, multiple recommendations (ACS vs. USPSTF et al.); and the assumption that “annual” is a default, no matter how artificial and un-evidence-based such an interval is.

I went to a great talk this week at the Berman Institute of Bioethics, and I’ll try to summarize it accurately (any felicities are the speaker’s, any errors mine). The speaker was Matt DeCamp, a friend of mine who – among other virtues – is enviably trained with a PhD in philosophy together with his MD. The bioethical question is this: how are we to understand the tradeoff between present costs and future benefits in the context of new drug development?

To understand this question, one needs to be acquainted with pharmaceutical R&D. It takes quite a bit of money, about $1 billion, over 10-12 years, to bring a drug to market. Drug companies make the most money of their product in the first 8-10 years after approval, after which time there is either voluntary price reduction on the part of the manufacturer, or a number of generics.

There are incentives provided to these manufacturers to invest in new pharmaceuticals. Familiar to most are patents (or copyrights/trademarks) which grant protection from copying and therefore a monopoly. Less familiar is data exclusivity, under which (according to Federal law) companies are prevented from marketing a product based on the same clinical data for 5 years. This grants a monopoly even if no patent exist.

Data exclusivity, it turns out, brings significant economic value with it for the company. I won’t go into detail, but Matt brought the examples of Glucophage and Colcrys.

“Health care reform” (PPACA) proposed a 12-year exclusivity for biologics. Matt then took the case of three people he made up, members of three different but overlapping generations.  How much can we ask of the oldest generation, who pays for this exclusivity without reaping the expected benefits? This is a separate ethical question (and this was one of the central points of the talk) from intergenerational justice with regard to distant generations.

For overlapping generations – e.g., members of generations who are living today, but older/younger than others – the questions are how to balance short-term costs and benefits, and not to lose sight of the fact that, while an individual proposal might be cost-neutral in the medium to long term (e.g. data exclusivity extended to 12 years), its short-term effects might fall disproportionately on certain age groups.

Should the oldest generation be expected to pay in more than it takes out? Matt’s argument was no – briefly, that a human right to health would be left unfulfilled if access to certain medicines is part of this right to health, and if costs unfairly fall in disproportionate fashion on certain groups.

Different concerns obtain, however, in thinking about distant generations. (Here he referenced the non-identity problem; briefly, can we expect, or assume, that our actions will have an affect on future individuals? This is relevant, apart from philosophical concerns, because some hold that human rights are not a property of groups, but properly only of individual human beings.)  If we are uncertain what will happen in future generations, or if we cannot accord them the assumption of identity, can we – our current generation – trade away a future generation’s right to essential medicines?

Balancing our present needs against future generations’ needs requires, Matt said, addressing several thorny questions: the value of a human life; the social discount rate; and the health discount rate. In any case, we need to accept either that future generations do not have rights, and priority should be placed on access now – or that they do have such rights, and we need to work on the tricky balancing act.

Matt closed by mentioning a number of radical policies which might mitigate, but not eliminate, the issue of intergenerational justice. These have to do with eliminating data exclusivity, to “allow immediate generic production, which would lower prices and increase access today, which could force more widespread social dialogue about intergenerational justice.” 3 alternatives he mentioned to monopolistic pricing are prize funds, advanced market committments, and public funding of clinical trials. He also mentioned less radical options, and counseled attention to intergenerational justice and the assumptions involved in calculating future risks and benefits.

This is an incomplete summary of his talk, which I hope to see in article form soon (in particular I left out graphs, figures, and health-economics language). He set a high bar for my own talk at the same seminar series, which I am giving next month.

I checked, by the way –  I did the Googling myself. 

Medicine is a profession, and professionals prefer the status quo. We stable middle-agers have a lot to lose. 

But what would it mean to occupy medicine? 

1. Patient-centered care without compromise.

2. Quality care without regard to perverted economic incentives or institutional hideboundedness.

3. Socially conscious medicine implementing public health.

Let’s add to the list. Can we occupy medicine incrementally, within our institutions and currently existing structures?

I never promised you topicality, but even I am embarrassed that my reaction to this article is three weeks late.  In the New Republic, the versatile Sabbath-supporter Judith Shulevits summarized the danger to health that some public health experts and toxicologists see from plastics and other ever-more-widespread environmental pollutants. On the cellular, molecular, and – in general – toxicological level, her summaries are convincing. But the transition I was waiting for – from “this might be dangerous” to “these plastics can cause increased rates of this particular disease, and here’s why” – never came. Instead, I got this frustrating paragraph:

By now, you may be asking, if our health is so sensitive and if we live in a total plastic environment, why aren’t we sicker than we are? And sicker than we used to be? The answer is, we’re healthier in some ways and sicker in others. Medical adances mean we’re likelier than ever to survive our diseases, but all kinds of diseases are on the rise. Childhood cancers are up 20 percent sine 1975. Rates of kidney, thyroid, liver, and testicular cancers in adults have been steadily increasing. A woman’s risk of getting breast cancer has gone from one in ten in 1973 to one in eight today. Asthma rates doubled between 1980 and 1995, and have stayed level since.  Autism-spectrum disorders have arguably increased tenfold over the past 15 years. … Obesity, of course, has been elevated to the status of an epidemic.

Of course. So what has this to do with plastics?

There are many ways to explain upticks in rates of any particular ailment: for starters, a better-informed populace and better tools for detecting disease mean more diagnoses. Other environmental stressors include Americans’ weirdly terrible eating habis, our sedentary lifestyle, and stress itself. Still, in [NIEHS director Linda] Birnbaum’s talk at the National Academy of Sciences, she declared unequivcally that data from animal studies “support a role” for environmental toxins as contributing players in a long list of ‘important human diseases.'”

That’s the only evidence we get (buried somewhere towards the end of the 4th page of a 5 page article) that environmental toxins might actually have concrete effects on the rates of real diseases that affect people, not laboratory animals or molecules. “Data from animal studies support a role.” With so many public health priorities involving billions of lives that are ended or cut short by concrete diseases, how much attention should we pay to toxicological worries for which evidence of real health effects is still lacking? Not much, I think.