Book review: Deadly Monopolies

I just finished reading  medical ethicist Harriet Washington's latest book Deadly Monopolies, a look into the world of the pharmaceutical industry.

Back in the good ol' days, universities and hospitals were the breeding grounds for new medicines. Researchers collaborated in order to find ways to fight common disease. Most new discoveries weren't patented because the research dollars came from the federal government.

That all changed in 1980 with the Bayh-Dole Act that allowed corporations, universities and hospitals to patent their discoveries even if the funding to conduct the research came from US taxpayers. At that moment, medical research ceased to be a race to find the cure and became, instead, a race to lock in profits. When that is factored in along with a newfound ability to patent genes, cell lines and other biological material, big pharmaceutical companies stood to make vast fortunes.

Along the way the concept of "informed consent" was cast aside as it was a hindrance to labs, hospitals and drug companies testing their wares on the public. So much for ethical considerations - we have money to print.

In the United States, hospitals across the country subjected patients to trials involving artificial blood. No one asked these patients if they wanted to participate in the study - if they happened to be taken to the right emergency room in the right city, they received the artificial blood.

The attempt may have been noble - as may have been the trials involving substitutes for saline solution for patients who suffered a traumatic injury in the field - but the method was not. The people who received the artificial blood were never consulted to determine if they minded being guinea pigs. They were never informed of the possible risks involved in pumping the artificial blood into their bodies.

In Africa the drug companies conducted trials of drugs to fight the scourge of AIDS. But there was a catch. In trying to determine how effective the new drugs were in fighting AIDS, the control group in the trial was given a placebo. That's right - some in the study were condemned to die while others received a chance to live.

In this country a test conducted under that dynamic would never be allowed. In order to test the effectiveness of a new treatment, the control group needs to receive the currently accepted standard of care. This gives researchers the ability to compare the effectiveness of the varied treatments. Under no circumstances should a person be allowed to die because he's been given a placebo.

Researchers argued that the trials were ethical because the current accepted standard of care in Africa for AIDS was no treatment at all. And, of course, none of the test subjects were ever told they might be given a placebo rather that the real drug.

If you're not irritated enough at the high cost of health care and prescription medications, after you read Deadly Monopolies, you will be.

County proposes plan to ration health care in case of emergency

If you're unhappy about the way your insurance company likes to question your doctor about the appropriate treatment for whatever ails you, you're going to love the new Harris County plan for dealing with a future flu pandemic.

After two years of drafting, the county is finalizing a plan on how to ration ventilators in the event of a flu outbreak the likes of which haven't been seen since the 1918 Spanish influenza epidemic that afflicted 500 million people and killed 50 million.

County officials have decided who will have access to a ventilator and who will be left to suffocate to death. Estimates are that a pandemic could cause over 10,000 residents to need a ventilator. Unfortunately, there are fewer than 400 unused ventilators in the county.

The Harris County plan notes that many patients with bird flu have required mechanical ventilation within 48 hours of hospitalization. In the event of a severe pandemic event, as many as 10,231 infected Harris County residents would need ventilators, the plan says, a number in addition to those already on ventilators for other conditions. Typically, there are less than 400 unused ventilators in Harris County at a given time.

Under the county's plan, folks needing the use of a ventilator would be placed into one of three categories: (1) patients who are healthy enough to recover without the use of a ventilator, (2) patients who are so sick that a ventilator won't matter and (3) patients who are sick but will recover with the use of a ventilator.

But it won't be the treating physician who will make that call. Nope. Say hello to the hospital review officer. That's right. A mid-level manager will be making those life and death decisions for you should you find yourself in need of a ventilator. After all, we can't possibly leave those kinds of decisions in the hands of medical professionals who have trained for years in the art of diagnosis and treatment - they'd just want everyone to have a ventilator. We need a bureaucrat with a pocket protector to work the calculus to determine who lives and who dies.

Lisa L. Dahm, an adjunct professor at South Texas College of Law, suggested that, in order to avoid lawsuits, county officials should push to suspend laws that require doctors to treat their patients with life-threatening conditions. Way to go, Ms. Dahm. Just brilliant how you took the focus off the ethics of a hospital administrator playing God to focus it on how to reduce the county's liability when someone's grandmother dies because the plan says she doesn't get a ventilator.

"These are difficult conversations none of us like to have. But the reality is, in a severe pandemic, there'll be serious shortages of medical resources and it behooves us to make the best possible ethical and clinical deliberations in advance about who should get them." -- Dr. Herminia Palacio, Director of the Harris County Health Department

In an ideal world we'll never know the public's reaction to the plan because the dreaded flu pandemic will never come. But, the increased use of flu shots will only serve to strengthen the resistance of the virus (much like gonorrhea has overpowered our arsenal of drugs). Oh, that damn law of unintended consequences can be such a bitch sometimes.

The public was invited to participate in the discussions and each participant received $75 per day. Would the fact that these meetings were held during a time when there was no fear of a pandemic affect the discussions? Would the fact that participants received a small stipend have an effect on the outcome of the meetings? William Winslade, an ethicist with the University of Texas Medical Branch thinks so. Hey, it's easy to toss around ideas like that when there's no pandemic in sight. And who would complain when they're getting paid much better than jurors to sit around a table and discuss the issue?

It's interesting that this plan is being drafted by unelected officials instead of the commissioners chosen by the people to govern the county. Is that because Ed Emmett and company don't want to take the heat from residents about rationing health care in case of an emergency? One would think that elected public officials who are paid by our tax dollars would have enough integrity to take a stand.

But, I've learned over the years never to start a sentence with the phrase one would think.