Hooked: Ethics, the Medical Profesion, and the Pharmaceutical Industry Review

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(More customer reviews)from The NYTimes- April 24, 2007
Medicine and the Drug Industry, a Morality Tale
By ABIGAIL ZUGER, M.D.
It was in 1949 that Elvin Stakman, president of the American Association for the Advancement of Science, issued the membership their marching orders: "Science cannot stop while ethics catches up."
And sure enough, from bombs to clones, the ethicists have generally kept to the rear of the scientific parade: they are the ones with the big brooms trying to restore order after the floats and the elephants go by.
Those brooms sweep slowly. Often, by the time the ethicists finish laying out facts and weighing relevant moral values, the worst of any given crisis has passed. But recently, those who work in medicine have moved closer to the fray: they staff acute-care hospitals and monitor events in real time, aiming for a little less retrospective philosophy and a little more damage control.
In this proactive spirit Howard Brody, a medical ethicist, has brought his discipline's tools to the relationship between the medical profession and the pharmaceutical industry. This problematic tangle of moral compromise (or triumphant health-promoting collaboration, depending on your point of view) has inspired several polemics by physicians in recent years, all of them straightforward indictments of the pharmaceutical industry and its for-profit webs.
Dr. Brody is also a physician, but he aims for the measured cadences of the ethicist instead, calmly laying out the relevant facts and then reasoning from basic principles to determine whether the medicine-pharmaceutical relationship, as it stands now, is an ethical one or not.
That Dr. Brody manages to deliver a hundred-odd pages of determinedly objective analysis before he, too, lets the righteous indignation roll should not really be called a failure of methodology: even as he carefully lays out the facts in this impressively comprehensive book, those facts begin to speak damningly for themselves.
The small-time operations that grew up into modern medicine and Big Pharma joined together back in the late 19th century, allied in the name of scientific medicine against a variety of dubious health-care entrepreneurs. The A.M.A. actually called the early pharmaceutical companies the "ethical" drug makers, to distinguish them from unscrupulous patent-medicine peddlers.
Over time, this casual alliance has been reinforced with such complex and often invisible bonds that, in Dr. Brody's title metaphor, medicine and pharma are now "hooked" like two pieces of Velcro, tethered by a million barbs and as dependent on each other as any addicts are on their substance of choice.
Dr. Brody systematically analyzes the levels of connection, from the lowly drug salesman buying lunch for a roomful of medical students (future customers all) to the lucrative contracts and patents that simultaneously fuel medical research, fill corporate coffers and give us, as the industry doggedly and quite correctly points out, dozens of truly miraculous life-saving drugs.
Many of these interactions are probably now familiar to most readers: the omnipresent logo-bearing trinkets festooning medical offices, the free samples of the latest, most expensive drugs, the "ask your doctor" television ads.
Less familiar may be some of industry's other friendly overtures: the lavish junkets and cash rewards for some "high-prescribing" doctors; the subtle manipulations of research data; the way-too-generous financing of postgraduate medical education; the very cozy relationship with the Food and Drug Administration and its physician consultants; and a casually Orwellian interference with the average physician's prescription pad.
A drug salesman recalls for Dr. Brody the time his company asked a local doctor to evaluate various sales presentations for a particular drug: "He'd been selected because our data showed that he was a relatively low prescriber. ...Basically, the company was willing to bet $500 or $750 that if he heard the same drug pitch all day, by the end of the day he'd be so brainwashed that he could not possibly prescribe any other drug but ours."
All this mutual back-scratching would be fine if patients' interests were indeed being served. But ample data indicates quite the reverse. Patients, after all, are the ones who pay for expensive drugs when cheaper would do as well, and the ones who swallow dangerous drugs nudged to market by their manufacturers.
Many individual problematic drugs make an appearance here. Chloromycetin, a toxic antibiotic from the 1950s, was relentlessly promoted by its manufacturer for routine use until the day its patent expired. (Still available in generic form, it is now used only as a last resort.) Thalidomide never caused an epidemic of birth defects in this country, as it did in Germany, only because a single stubborn F.D.A. officer was dissatisfied with the drug's safety profile, despite the manufacturer's repeated assurances that everything was fine.
The epitaph of the recently withdrawn painkiller Vioxx, whose virtues were subtly spun to the medical community in prestigious research journals, is still being written in litigation around the country.
"Research that is driven by marketing rather than by scientific aims would seem, in the end, to be low-quality research," Dr. Brody comments mildly about the Vioxx fiasco.
His overall conclusion is similarly low-key: "A profession is not just a way of making money; it's a form of public trust. ...Medicine has for many decades now been betraying this public trust."
It is not a particularly surprising conclusion, and, in fact, there is relatively little in this book to surprise anyone familiar with the territory. Rather than new material, it provides a meticulously referenced compendium of all the relevant history and commentary (including, for full disclosure, excerpts from one of this reviewer's columns in this newspaper).
Its breadth translates into a lack of depth in some areas, especially the final section, in which Dr. Brody tries to outline a feasible solution to the mess. His suggestions are cogent but a little skimpy, given that absent an act of God, it will probably take an act of Congress to pry medicine and industry apart someday, preferably as part of thoroughgoing health care reform.
Still, for a detailed overview of this very jagged terrain, if not for a map of the pathway out, a better general guide than this one is hard to imagine.
Abigail Zuger, a regular contributor, is a physician in Manhattan.


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The Logic of Health Care Reform: Why and How the President's Plan Will Work; Revised and Expanded Edition (Whittle) Review

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(More customer reviews)The Logic of Health Care Reform is like countless other books, which is what makes it so depressing to read. Its subtitle -- Why and How the President's Plan Will Work -- refers not to the current president, but to Bill Clinton. It came out in 1992, came out with revisions in 1994, is available for a penny used on Amazon, and stands as a very sad reminder of the hopes with which people greeted Clinton's plan.
What is hopeful about The Logic of Health Care Reform is that Paul Starr laid the groundwork for a new progressive media. He cofounded The American Prospect in 1990; it's a breeding ground for some of the brightest lights in progressive media, among them Ezra Klein, Jon Cohn, and Josh Marshall. The hope, looking backwards with some trepidation, is that Clinton's failure arms us for success now. Of course we can't know. If health reform succeeds under Obama, a long cast of protagonists will be adorned with floral wreaths and paraded before the townspeople; if it fails, it will be painted as inevitable, and those same protagonists will be painted as pusillanimous and ultimately valueless. Where I stand right now, it could go either way.
In any case, Starr's book came out in the thick of the debate over the Clinton plan, and the blurb describes him as "one of the plan's architects." It contains the same litany that we've read countless times before: the insured population shrinking precipitously; small businesses as victims because of their limited bargaining power; health care costs growing much faster than the overall rate of inflation; health-insurance costs rising while wages remain stagnant, and indeed rising health insurance probably accounting for immobile wages. Firms have a finite bucket of money, after all.
I've come to realize that The American Prospect and its derivatives tend to be wonkish. They focus on the economics of health reform, instead of the moral urgency that impels us, as a just society, to help out those who are less fortunate than we are. A glorious exception here is Jon Cohn's book Sick. You should probably read Starr's book and Cohn's back to back; that would give you a picture of why health reform is not only the morally right thing to do, but makes economic sense.
The centerpiece of the Clinton plan was "managed competition." First, there's competition: some organization, called the "sponsor" -- typically an employer -- offers a menu of competing insurers to its members. Members choose their insurer once per year, when they're not expected to be sick and can choose with a sound mind.
The second piece corresponds to the word "managed". Unmanaged insurers could undercut their competitors by offering plans that cover less, or by only insuring healthy people. Regulation, then, would require that insurers compete on a standard plan, and must offer it to everyone regardless of health. The plans would be required to be "community-rated," which is to say that they'd offer the same rates to all their subscribers. This would mean that plans which ensure an older or sicker customer base would tend to have higher premiums. Hence the sponsor would reimburse plans more if they have a sicker customer base, less if they have a healthier base.
Starr does a good job laying out the various moving parts in health-insurance reform. One of these days I'll sit down and map out exactly how those moving parts interact. If we want universality, for instance, insurance must be required; otherwise adverse selection kicks in, and the healthiest patients drop out of insurance, leading to a downward spiral where only the sickest are insured. Then it becomes a question of who should be required to pay (e.g., employers, employees, the government, ...). Some people will not be able to afford coverage at any price, though; these people will need financial help, which then forces us to ask how to help those people. Then there's the question of how to separate health coverage from employment status: whether you find and treat your heart disease shouldn't depend upon who your employer is. Tweaking any one of these moving parts causes adjustments in the others, but the total number of moving parts does seem rather small.
Starr's book is another tool in the armamentarium. At this point in my education, it seems deeply foolish, when it's not actively harmful, to reject a government role in regulating the health-insurance market. Doing so would almost certainly make the market function better for consumers. People have been talking a lot lately about having a health-care "conversation." By all means, let's have that conversation. The first question is: do you believe that it is even a problem that 1/6 of your fellow-Americans are uninsured? If not, there's not much to talk about. If you do think it's a problem, the onus is on you to explain why the government shouldn't require insurance of all Americans. Let's start that discussion, and let's use The Logic of Health Care Reform as a starting point.

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The Pulitzer Prize-winning author of The Social Transformation of American Medicine reveals that President Clinton's plan for health care reform will work because it was devised by taking the best ideas from a variety of proposals that reflect the full range of the political spectrum.

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