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Topic: Distributive Justice
December 27, 2012 | Posted By Bruce D. White, DO, JD

In 2012, the percentage of money spent on providing drugs to patients in the United States continued to rise (Hoffman et al., 2012). However, this is a US trend not seen in other developing countries – such as Canada – where national drug expenditure percentages are slowing year after year (CBC News, 2012). In fact, in Canada, the rate of drug cost growth for this year is the lowest of the last 15 years. 

So, why? Simply put, the American pharmaceutical industry has fueled new drug innovation worldwide for decades. Now, the pharmaceutical companies have less money for research and development and are innovating less. When they do innovate, the companies spend their R&D allocations either on “me too” (imitation) drugs, or very, very expensive drugs for which insurance reimbursement is maximized. Market forces drive both these new drug lines. But now, the R&D well is clearly drying up (Adams, 2011).

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

December 12, 2012 | Posted By Wayne Shelton, PhD

Recently, I attended a debate between two very informed health care professionals about whether or not our country should have a single payer health care system. Each seemed to have their own philosophical or ideological perspective about health care as a basic service in our society and it through their ideological lens that each speaker viewed health care and brought to bear the facts to support their positions. It was striking that these two very informed and thoughtful individuals often disagreed about fundamental facts pertaining to our health care system. 

For example, the opponent of a single payer system supported his claim that turning over health care to the federal government would be a failure at least in part on the assumption government is incompetent to perform this task. He claimed, as other thoughtful conservatives do, that that Medicare and Medicaid are less efficient than private health plans. If the analysis in the first link below, which is part of the Ryan Plan, is true, then perhaps there are some facts to support their case.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit ourwebsite.

November 9, 2012 | Posted By Bruce White, PhD

Almost everyone now must have heard about the New England Compounding Pharmacy tragedy that has been unfolding over the past month. The Centers for Disease Control and Prevention in Atlanta (CDC) numbers the present death toll at 28 and total reported cases at 377 from 19 states. Untold thousands of patients may have been injected with contaminated medicines. The New York Times has called this situation “one of the worst public health drug disasters since the 1930s.” 

Already there are more calls for stricter regulations and controls for compounded medicines that enter interstate commerce. The New York Times reported on November 2, 2012, that Representative Edward J. Markey (D-Mass.) will be introducing a bill to oversee compounding pharmacies with wide-scale operations be regulated as “manufacturers” by the Food and Drug Administration (FDA). Calls for greater regulation of compounding pharmacies are not new; the FDA has been attempting greater control for at least the last 20 years.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

November 1, 2012 | Posted By Paul Burcher, MD, PhD

When former President Bill Clinton spoke at the Democratic National Convention, he argued that we must put aside ideologies to “get things done.’”  The implementation of the Affordable Healthcare Act (ACA) is challenging Republican governors on exactly this point, and their responses are not uniform.  Jan Brewer, governor of Arizona outspoken critic of President Obama and the ACA, has begun planning for, and implementing the healthcare exchanges that states must create under the rules of the legislation.  States that fail to plan for exchanges will have exchanges created for them by the federal government. Six states with Republican governors have decided not to create exchanges, and may also not accept additional money from the federal government to expand Medicaid coverage along the lines set out by the ACA.

Is this just politics as usual, or is there an ethical dimension to this partisan debate?  I would argue that to fight against Obamacare to the detriment of the health of a state’s citizens—the poorest of the states citizens—is a violation of a politician’s duty to beneficence.  Uninsured patients suffer a preventable harm from the lack of access to healthcare, a harm that is now being remediated by the ACA, but only if only states will fully implement its policies.

October 3, 2012 | Posted By Bruce White, DO, JD

The September 20, 2012, issue of The New England Journal of Medicine carried two Sounding Board pieces about recommendations to contain health care spending. One article is titled “A Systematic Approach to Containing Health Care Spending” was produced by nationally known health policy experts working in cooperation with the Center for American Progress.

About half of the 11 recommended solutions are not new, nor have they proven to be anything more than platitudes from the past. Among these recommendations are: (a) “accelerate use of alternatives to fee-for-service payment”; (b) “simplify administrative systems for all payers and providers”; (c) “make better use of nonphysician providers [such as nurse practitioners and physicians assistants]”; (d) “expand the Medicare ban on physician self-referrals”; and (e) “reduce the costs of defensive medicine.” Should one peruse any one of several books produced in the 1980s written by politicians and health system gurus – such as Alain C. Enthoven’s Health Plan (1980), Joseph A. Califano, Jr.’s America’s Health Care Revolution (1986), Victor R. Fuch’s The Health Economy (1986), and Rashi Fein’s Medical Care, Medical Costs (1989) – they would find the same recommendations. Also, not so curiously, all of these authors and many others agreed in spirit – in the 1980s – that health care spending “trends [then] could squeeze out critical investments in education and infrastructure, contribute to unsustainable debt levels, and constrain wage increases for the middle class.” This at a time when total health care spending was one-tenth of what it is today (health care spending in 1980 was $256 billon; health care spending in 2020 was $2.6 trillion).

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

September 21, 2012 | Posted By Bruce D. White, DO, JD

In a recent article about medical repatriation in a national bioethics journal, philosopher Mark Kuczewski argues that the practice can be an “ethically accepted option” only if three conditions are met:

  1. Transfer must be able to be seen by a reasonable person as being in the patient’s best interests aside from the issue of reimbursement.
  2. The hospital must exercise due diligence regarding the medical support available at the patient’s destination.
  3. The patient or appropriate surrogate must give fully informed consent to being returned to another country.

Surely Dr. Kuczewski knew – when he wrote the article – how completely absurd these three “conditions” or prerequisites are?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

September 13, 2012 | Posted By Wayne Shelton, PhD

The Supreme Court ruled this past June that the Affordable Care Act (ACA), otherwise known as Obamacare, was indeed constitutional. But this ruling only occurred when Chief Justice came over to the more liberal side. However, he made it clear that the basis for its constitutionality could not be the commerce clause but rather the right of the federal government to impose new taxes. That is, the government could not require citizens to buy certain services but they could, via elected representatives, impose new taxes to support those services. On the conservative side, there seems to be the notion that health care itself is a normal market service or product like any other. Requiring someone through the imposition of a mandate to purchase health care is therefore the same as requiring them to purchase broccoli. Though most of us on the liberal side are glad that the ACA was deemed constitutional, it causes us considerable pause to leave just a wrongheaded legal understanding embedded in our public policy moving forward.

Broccoli has many health benefits. It is filled with vitamin A and C, folic acid, calcium and fiber. It may help prevent high blood pressure and colon cancer. And it’s really delicious steamed up as an accompaniment with other vegetables and almost any meat or carbohydrate. In fact I would prefer to spend the remaining time in this blog describing all the ways broccoli can be enjoyed and used to promote health. But my point here is only to say, as wonderful as broccoli is, it is dispensable in one’s diet. Former President George H. W. Bush famously claimed his right to refuse to eat broccoli any longer because he was now president and could do as he wished. He just didn’t like it. And as difficult as I find it to empathize with such a sentiment, I must say, it makes virtually no practical difference either to former president Bush, society and to the marketplace in which broccoli is sold. He will hopefully find other vegetables he finds more palatable or take vitamin supplements, or just hope that his genes help him get to a long life. There are countless market products and services just like broccoli, in terms of being really, really good for you, but if you don’t buy them, neither you nor the rest of society will be harmed.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

August 7, 2012 | Posted By Bruce White, DO, JD

With the Supreme Court upholding the individual mandate of the Affordable Care Act (ACA) constitutional but rejecting the notion that the states had to expand their Medicaid program to cover a significant percentage of the populations, some inequities in health care delivery will only grow.

One might use any number of examples to illustrate identified expected unfairness. For the relatively poor Southern states – Alabama (AL), Louisiana (LA), and Mississippi (MS) – patients covered by Medicaid and the Children’s Health Insurance Program (CHIP) is significantly higher than the national average now. With the proposed ACA expansion in these three states effected by 2019, the percentage of Medicaid & CHIP-eligible populations would swell from 20% to 27% (AL), 26% to 34% (LA), and 26% to 37% (MS). In Louisiana and Mississippi, these percentages are approaching the number of persons in the state who have traditional private health insurance. [The projected numbers used here are from the Kaiser Family Foundation Website.]

Moreover with the increased numbers of patients who will have Medicaid and CHIP coverage, proportionately more practitioners will be critical in providing the care in these states. Is it realistic to think that Alabama, Louisiana, and Mississippi, will be able to grow their provider availability by 37%, 32%, and 41% in four years to meet the demand? The national average is 25.7 active physicians per 10,000 persons. Louisiana is very close to the US mean with 24.2 physicians per 10,000, but Alabama and Mississippi are will below the national average with 20.6 and 17.3 physicians per 10,000 respectfully. Is it reasonable to assume that these states will be able to multiply their physician populations to meet any increased demand?

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

July 9, 2012 | Posted By Jane Jankowski, LMSW, MS

Historically, palliative care has not been associated with pediatrics. In western societies children are expected to outlive their parents, and we prefer to avoid the sad reality that kids do sometimes die. This social dismay could, in part, explain why the development of palliative care programs for children has lagged behind the adult programs. Not to be confused with Hospice, palliative care is a medical specialty which focuses on symptom management for patients with serious, often life threatening, illnesses. Admission to most Hospice programs requires a six month maximum life expectancy, whereas palliative care may be offered alongside curative treatments to alleviate burdensome side effects and symptoms. In the US, the passage of The Patient Protection and Affordable Care Act of 2010 has improved access to end of life care for children because the legislation permits concurrent coverage of medical treatment and Hospice services. Though a significant step forward, gaps in service may remain because children can live longer with serious illnesses and not meet the six month life expectancy criteria required for admission to a Hospice program. A better prognosis ironically leaves them without access to Hospice’s aggressive symptom management and compassionate, holistic care model. Pediatric palliative care services are emerging to meet the needs of children who have life limiting conditions, but are not expected to die in six months or less. Perhaps the most important feature is that palliative service can be provided alongside treatments for serious illnesses with very good prognoses. 

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

January 24, 2012 | Posted By Posted By David Lemberg, M.S., D.C.

A recent New York Times article cast a critical eye on one of the latest entries in the high stakes, high technology medical arms race. Proton beam therapy, the procedure under discussion, purports to treat cancer. But even though not a single randomized clinical trial has been done, Medicare is still willing to shower 50,000 scarce Federal dollars to providers for proton beam therapy for prostate cancer.

Considering that there are no studies evaluating the long-term outcomes, and no studies evaluating potential serious side effects of proton beam therapy, Medicare might just as well be burning $25,000 every time it pays for such a procedure. Worse, this is not an isolated scenario.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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