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January 24, 2012 | 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 on providers for proton beam therapy for prostate cancer. This sum is approximately two times as much as Medicare pays for another type of radiation.

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. Despite the FDA's revocation of approval of Avastin for the treatment of breast cancer, the New York Times reported that Medicare will continue to provide coverage for the use of Avastin in breast cancer treatment. The cost of this drug is close to $90,000 per year. The FDA commissioner had noted that clinical trials demonstrated that Avastin was not assisting breast cancer patients to live longer. Avastin was not meaningfully controlling their tumors. Side effects of Avastin were demonstrated, including severe hypertension and hemorrhaging. Regardless, huge tax dollar sums are being spent on a treatment that is ineffective at best. Such a policy was described in 1976 as "The best available to all. That is what we tend to do today for those groups whose medical care we do underwrite."1

Many deep issues are in play. The issue of equitable distribution of scarce resources is an obvious concern, at least for those who believe that federal health care dollars should be allocated based on sound scientific evidence. Of course, a more contentious position would involve resource distribution based on maximizing the recipients of a given level of federal support. One $50,000 proton beam therapy could equal 100 or more complete physical exams for persons who haven't been able to afford a check-up for years. Such a policy, radical at present, would provide a lot of good for a lot of people. Patients whose expensive, but unproven, treatment was no longer being paid for might not agree with such redistribution.

Another deep issue relates to the conflation of technological medicine with improved outcomes. It is often said that America offers the finest quality health care in the world. The point is debatable, but it is a fact that only a very few can afford such high quality care. Recent data demonstrate that more than 59.1 million Americans do not have health insurance of any kind. Beyond this, chronic disease persists unabated in the United States, despite the ever-increasing annual expenditures on "health care". We are in the midst of obesity and diabetes epidemics. For example, type 2 diabetes used to be known as adult-onset diabetes, but has been seen in increasing frequency in younger people for many years. With respect to type 1 diabetes, not only are more new cases appearing every year, but an earlier age of onset is apparent. The U.S. is far from being the world leader in life expectancy. On the other side of the spectrum, we are far from being the world leader in infant mortality rates. What exactly are we getting for our touted quality of care?

With respect to health care, more is obviously not better. Specifically, throwing more technology at chronic diseases such as cancer is not better. As an aside, coronary artery disease remains the number one killer of men and women in the United States, accounting for 20% of all disease-related deaths.

Rather than subsidizing payments for infrastructure of dubious value (such as proton beam machines (costing $180 million), the goal of federally financed health care should be to provide the greatest health care benefits to the most people. This requires starting with the "basic proposition that health care is a right, not a luxury". What is needed is a "reordering of priorities, a strengthening of resources, and a restructuring of services".2

1Fried C: Equality and rights in medical care. Hastings Center Report 6:29-34, 1976

2Corman J: The Health Security Act. In National Health Insurance Schemes. Institute of Industrial Relations, UCLA, 1972, p 6

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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