The Business of Drugs

I went to my first drug rep dinner the other night at Smith & Wollensky in Houston’s Highland Village.  The high-end steaks and 20+ bottles of wine left nothing to be desired by the nurses and physicians in attendance.   Research shows that being wowed with a nice meal influences later decision-making.  Yes, I could see how the memory of one of those juicy steaks could prompt a doctor to select a particular medication.

Special thanks to Joe Gibes for bringing to light how pharma business practices stymie important medical treatments.  I worked in business for over 7 years, and I saw two types of businesspeople.  One type focused on presenting the merits of the product and gave the buyer room to evaluate it and make a decision on a purchase.  This person would refrain from the pressure sales pitch and would frankly state what the product could and could not do.  Sometimes this went so far as recommending a competitor who sold a product that fit the customer’s needs better.  The other type of salesman I encountered had a different approach.   Marketing techniques were more about allurement rather than presenting one’s ware.  These folks were jovial types always given to conversation, but all the backslapping often left the customer with an uneasy feeling.

Business reform in general is needed in our country, but more is at stake when unethical business practices impact the field of medicine.  Since a person’s well-being is in the balance, extra care and protections must be employed.  I often hear medical students comment, “I can’t really do anything about the drug business.  It’s just the way things are.  I might as well enjoy the free meal.”  But don’t we owe it to our patients to remove any taint from medical care when their very lives are concerned?  Our Savior was a humble man, and there is no doubt his humility opened the door for His effective healing ministry.  Such a disposition sets an entirely different tone for healthcare, which our medical system desperately needs.

Physicians, Technicians, Clinicians, and Providers

A few weeks ago I had lunch with two doctors who are currently in a residency training program.  In a moment of candor, both of them remarked, “I feel like I’m being trained as a technician.”

This comment struck me as tremendously important (and not just because I am heavily involved in their training and their words highlight my failure as a teacher!).  Because if their perception is correct — if we are indeed instilling in future physicians the ethos of the technician — then we had best be prepared for the inevitable results.  “To a man with a hammer, everything looks like a nail;”  to a technician, every problem looks like a technical problem, one which needs to be solved by a technique or technology.  The dizzying upward spiral of health care costs is driven largely by the increasing use of increasingly expensive technologies;  training a technician workforce can only exacerbate the problem.  The technical bias towards the automatic, unreflective use of technology simply because it exists will lead to more of the inappropriate use of technological interventions that are the bread-and-butter of hospital ethics consultations.

But more importantly, not all problems in medicine are technical problems;  some are singularly resistant to simplistic, technical solutions.  For some conditions, the doctor is the best drug:  his or her human, caring, and compassionate presence, just being with the patient.  Yet to the technical mindset, this simply attending to the patient (from which we get the expression “Attending Physician”) is discounted in favor of doing things to patients;  and while both the being and the doing are necessary for the practice of good medicine, the standardization, mechanization, and industrialization of medicine in our day has heavily favored the latter at the expense of the former.  More often than our technical mindset acknowledges, it is better not to do something to the patient;  but this option is not in the purview of the technical mindset.  We always feel we must do something, and medical caring  often suffers as a result.  The central economy of medicine, the physician-patient relationship, is lost in the technical mindset.

The ongoing industrialization of medicine is reflected in and driven by the terms we use to describe doctors.  In the May 25th JAMA, the authors of an essay entitled “Dear Provider” wrote of the replacement of the title “clinician” with “provider.”  The authors believe that this semantic change could be subliminally altering professional self-concept and behavior, “shifting the clinical encounter from patient-centered to task-oriented.  Nowadays, patients are quickly ‘plugged in’ to templated workups;  progress notes have become computerized inventories of completed tasks;  and when we ask residents on teaching rounds ‘What do you think?’ we often hear ‘I think I want to get an MRI.’  It appears that the time and effort spent by providers packaging patients through the system is displacing most other clinical activities.”

Packaging patients through the system. Sounds like a technician’s handiwork to me.  How did we get to this?  Do we turn back or go on?

 

Another Point for Adult Stem Cells?

A recent development in (Adult) Stem Cell research has proven effective in repairing the heart muscles of mice after a heart attack! Although the procedure has only proven effective–thus far–on mice, the promise of cell reactivation repairing muscle after a heart attack is nothing to sneeze at.

“The researchers examined the hearts of mice at various time points after the operation [procedure that replicates the effects of a heart attack]. They found heart cells expressing Wt1 just two days after the injury. The cells were initially in the heart’s outer layer, but by two weeks after surgery they had moved inside and clustered around the site of the injury. The cells had also changed in size and shape, and looked just like cardiomyocytes.”

This success is another reminder that we (scientists and researchers of today) are still needlessly pursuing the less than ethical embryonic stem cell research that requires the destruction of human embryos, the ending of human lives.   When comparing the two it is difficult to not concede to the preeminence of embryonic alternatives, and still the federal government wishes to fund the destruction of embryos.

While the battle continues, it looks like embryonic alternatives still have the upper hand.

For more information on stem cell research check out this website.

 

 

 

 

Thanks, GAVI!

In a world full of inequities in health care including a child mortality rate in some developing countries that continues to be alarming, it is good to recognize those who are making a difference.  The Global Alliance for Vaccines and Immunisation (GAVI) recently announced that they had entered into agreements with several vaccine manufacturers to obtain vaccines for developing countries at reduced costs.

GAVI is an international organization that attempts to unite donor nations, private donors, developing nations, international organizations, and immunization suppliers to meet the goal of saving children’s lives and protecting people’s health through better access to immunizations.  In the ten years from 2000 to 2010 more than 288 million children were immunized with GAVI-funded vaccines, and an estimated 5 million deaths prevented.

Organizations like GAVI deserve our thanks and support for making a positive impact on the lives of children around the world.

Was I Wrong?

In an earlier blog (May 24), I wrote about the failure of liberal politics and the myth of neutrality.  I observed that “The negative consequence of neutrality is an inevitable deadlock; medical ethical decisions have to be made but our laws and policies lack any defining understanding of what is good.  Yet in order for a society to function, it must devise some means to achieve a common ground.”  I concluded that “I honestly see no workable solutions to this predicament.”  In other words, I implied that we are at an impasse concerning legislation and there seems to be no solution in sight.

Perhaps I was wrong!

The June 2011 issue of Christianity Today reports of “The New Pro-Life Surge.”  According to the article, “Political gains by U.S. conservatives unleash waves of anti-abortion legislation” (Christianity Today, June 2011, p. 17).  By April of this year, “142 abortion-related provisions had passed at least one chamber of a state legislature, compared with 67 in 2009.”  A slight majority of the measures aim to constrain a woman’s access to abortion services.  Indeed, abortion rates are down by 22% since 1990.  Moreover, for the first time the majority (again, a slight majority) of Americans consider themselves pro-life.

So the question is – how are we to interpret the latest news?  Are we winning some skirmishes of the culture wars after all?  Do we push forward with greater zeal, or remain content with our slight gains, knowing that pro-choice rights will never be reversed?

 

On the Death of “Dr. Death”

This past Friday, Dr. Jack Kevorkian, the ardent advocate of “physician-assisted suicide” (PAS) whose preoccupation with death earned from his medical colleagues the moniker “Dr. Death,” died in a Michigan hospital after a protracted illness. On the manner of his death, his attorney, Mayer Morganroth,  reportedly commented, “It was peaceful, . . . He didn’t feel a thing” (cnn.com; 06/03/11).

If you ask most people their preference on how they hope their death will go down, you will, no doubt,  consistently encounter the anesthetic wish evident in Morganroth’s words. Who, in their right mind, would truly desire an intensely painful death? Not I, for one.

Yet, while we might all prefer a peaceful death, is it to be pursued at all costs? Kevorkian thought so, and so he risked his own freedom and reputation to provide for others a terminal escape from chronic pain and disability. Better it is, he reasoned, to take matters into our own hands by inducing a quick and seemingly painless end to life, than to endure the indefinite prolongation of an exceedingly unpleasurable experience.

In one word, Kevorkian was a hedonist – specifically, one tending to the order of Epicurus who viewed  the absence of pain and anxiety as sacrosanct.   Paradoxically, Epicurus took a dim view on suicide, but that inconsistency would be rectified by his followers who understood that if death is, as Epicurus had argued, the end of feeling (and existence), then it is to be preferred over a continuing state of unrelenting pain. Furthermore, there could be no fear of divine reprobation for those who ceased to exist.

As for the concern over divine judgment, Kevorkian, a self-professed agnostic, scoffed. How an agnostic can be so confident on a question of divine disposition is  a question for another post.  I’ll close this one with the observation that while  Dr. Death may be dead and gone, the push for PAS remains. Supporters are as determined as ever to harness the medical profession to the task of killing the disabled and infirm. The social barrier to “medicide” is fast eroding as a resurgent Epicureanism permeates our culture, and so, though a fringe figure at his death, Kevorkian may in the not-too-distant future be hailed as a national hero.

Your thoughts?

Your pharmaceutical company care$ about you (No, really, they do)

An editorial in the May 5th issue of the New England Journal of Medicine (NEJM) recounts the tale of Makena.  It starts back in 2003, when a landmark study funded by the NIH showed a decrease in preterm births for certain high-risk women who receive treatment with 17 alpha-hydroxyprogesterone caproate (17OHP).  17OHP is the only medication ever to have shown benefit for this problem;  therefore, on the basis of this study, it was used widely.  It was not a commercially available medication, but could be obtained from certain compounding pharmacies for about $15-$20 per weekly dose.

 

Many groups, hoping for a more easily obtainable and standardized drug, welcomed the FDA’s decision this past February to grant exclusive rights to Ther-Rx and KV Pharmaceutical Company to manufacture 17OHP under the name Makena.  Their welcome turned into astonishment when Ther-Rx announced that Makena would be priced at $1500 per dose.

 

Gregory J. Divis Jr., the pharmaceutical company’s chief executive, attempted to defend the indefensible by saying that Makena could help offset some of the costs associated with preterm birth, and that “These moms deserve the opportunity to have the benefits of an FDA-approved Makena.”  (The NEJM article estimates the total annual preventable medical costs associated with preterm births in this country to be $519 million.  At $15 per dose of 17OHP compounded in the local pharmacy, it would cost $41.7 million to attain those savings.  At $1500 per dose of 17OHP marketed as Makena, it would cost $4.0 billion to save that $519 million.)

 

The plot thickens.  On March 30th, the FDA issued a statement that it does “not intend to take enforcement action against pharmacies that compound 17OHP” when a valid prescription is written.  In other words, the FDA granted Ther-Rx a patent on the medication;  but when they saw the grievous abuse of that patent, they in essence revoked it!  (Was that an unethical reneging on a promise, or an ethically justified intervention to thwart pharmaceutical highway robbery?)  Ther-Rx generously reduced the price to a mere $650 per dose, and my OB colleagues inform me that Ther-Rx’s representatives have contacted many physicians’ offices and suggested that patients no longer have the option of using compounding pharmacies, but must instead use Makena.

 

It is not just Ther-X’s rapacity that is so breathtaking, but their audacity as well.  Has our society become so cozy with the idea of medicine as industry that a company actually has reason to believe it can commit such profligacy in broad daylight?  What part should the profit motive play in providing medical care?  Where’s the line between reasonable return on investment and unscrupulous opportunism?  Maybe it’s like what Supreme Court Justice Potter Stewart said about pornography:  I can’t define where the line is, but I know it when I see it.

 

I visited the Makena website, and read an online brochure that asserted, “Ther-Rx cares about you and your baby.”  I don’t doubt that they care;  I just wonder if they would still care if it weren’t so darned lucrative.

 

The End of the Food Pyramid

If you read my recent post entitled “The Human Factory” you may have begun to suspect that I am quite interested in food and the food industry. Connected with this intense passion for food is my interest in nutrition as it relates to physical training. So, when I heard of the new initiative of the US gov’t to reshape the nation through the replacement of the food pyramid, I was overjoyed and bewildered all at the same time.

Here is why:

My reason for being overjoyed is obvious–the current state of America’s health is horrible. This fact has correlative effects upon our health care system (i.e. increased spending on health care and increased demand on physicians).

I am bewildered because I am not sure that these new initiatives will have any impact on American Culture…

What do you think?

Is MyPlate going to be just another trend that fades away with time?

Will this public health initiative help us get out of our current state?

 

Suicide Assistance for Sale

The Oregon Senate recently approved a bill to ban the sale of suicide kits.  It is interesting that this occurred in the first state to legalize physician assisted suicide.  The move was in response to the death of a 29-year-old Oregon man who suffered from depression related to problems with pain and fatigue and took his life using a helium hood suicide kit that he bought by mail order for $60.  The helium hood method of suicide was developed and promoted by Derek Humphry and the kit was sold by a follower of Humphry to whom he refers business.  Humphry, who lives in the same area in Oregon as the man who committed suicide, founded the Hemlock Society that was a primary force behind the passage of Oregon’s assisted suicide law.

Although the Oregon law he helped to pass limits physician assisted suicide to those with a terminal illness, Humphry made it clear in an interview with The Register-Guard, the local Eugene, Oregon newspaper, that limiting assisted suicide to those with a terminal illness is not important to him.  Speaking of this particular case, Humphrey said, “It may be very sad and tragic, but if this man had ongoing health issues and had struggled with that, I wouldn’t criticize his decision.  It was his right.”

The logic of assisted suicide is clear.  If we accept that ending the life of the sufferer is an appropriate response to suffering and that a person who is suffering should be able to request assistance to end his or her life, then there is no reason to limit that assistance to those whose suffering we think is intolerable or who are terminal or who request the assistance from a physician.  A mail order kit fits the logic just as well.

Suicide by Mail Order

Recently The Los Angeles Times reported on Sharlotte Hydorn, the 91-year-old woman who sells mail-order suicide kits for $60.  Her reasoning is that people commit suicide “by jumping out of windows and buildings, and hanging themselves.”  With her kit, the task could be made easier.  As described by Richard Marosi of the Times, Hydorn “peddles a product touted for its deadly simplicity. Inside her butterfly-decorated boxes are clear plastic bags and medical-grade tubing. A customer places the bag over his head, connects the tubing from the bag to a helium tank, turns the valve and breathes. The so-called suicide kit asphyxiates a customer within minutes (Los Angeles Times, May 30, 2011).”

Apparently there is a demand for Hydorn’s suicide kits; individuals, young and old, terminally ill or despondent, have requested the “exit bags” on average 100 per month.  Hydorn is driven, she claims, not by a desire to make money, but by compassion.  From her perspective, to end suffering by means of suicide is the humane thing to do.  It’s not about killing people, she maintains, but about helping people who desire to end their misery.

I must admit that if and only if one removes God from the equation, Hydorn’s point of view carries some force.  After all, as Ivan Karamazov (of Dostoevsky’s The Brothers Karamazov) insinuates, if there is no God, everything is permitted.

So the question is how to argue against the promotion of assisted suicide without simply invoking God as the reason to reject it.  In other words, in a pluralistic society that appeals to a strict separation between Church and State, are the non-theistic arguments against assisted suicide strong enough to withstand the forcefulness of the arguments for assisted suicide?