Thursday, August 24, 2006

A Medical Ethics Issue Trod Under Foot

During my commute each day I listen to NPR. Indeed, if my wife hears me begin a sentence with, “I heard on the news today….” she’s pretty sure I heard it on NPR. This morning during my commute I heard on NPR’s Morning Edition three reports on health care that have raised significant ethical issues. One was on the possibility of producing embryonic stem cells without destroying the embryo. Another was on approval by the FDA of “Plan B,” the morning after pill to prevent pregnancy a a non-prescription drug. Both of those were interesting and important. And both of them would, I was sure, get lots of attention from news and blog writers.

I, however, was concerned with a health report that I fear won’t get near the attention it deserves, much less the attention of the other two issues. I heard this report on the search for new antibiotics – and the lack of interest of the commercial pharmaceutical industry in the research. Later on this morning when one of our physicians smiled and said, “So, let me think: is there an ethical issue today?” this one was my immediate response.

And make no mistake, this is a serious issue in medical ethics. We have wonderful medications, and a commercial pharmaceutical industry that has produced them. At the same time, the connection of drug research and drug development to profits does indeed put the research and development in jeopardy, and our health as well.

We in health care have been hearing for years about “drug resistant” bacteria. The causes are probably many, although a few have come to stand out. No antibiotic is perfect, and so some few bacteria will survive. When things go well those few that survive the antibiotic will not survive the patient’s strengthened and renewed immune system. But the patient who stops taking the antibiotic too soon because he or she has started to feel good again creates a gap. The bacteria, and especially those that are naturally resistant to the medicine, have a chance to multiply before the body is really strong enough to stop them. The patient who insists on taking an antibiotic for a condition that’s really viral creates a different sort of gap. Bacteria get exposed to the medicine, and some will prove resistant, while the immune system is weakened to fight the virus. Either way, evolution takes its course, and the bacteria that survive are those resistant to the medication. Finally, after years with no new mechanism for an antibiotic – no different way of attacking the bacteria – the resistant bacteria have had time to develop anyway.

All this is well known; and to some extent our health behaviors have changed. Family practice and pediatric physicians are less likely to prescribe an antibiotic at the first hint of discomfort, whether to the patient or to the family member taking care of the patient. Physicians and pharmacists have made efforts to do more education about the importance of completing a prescription. There is that classic story: the patient looks at the doctor or pharmacist and asks, “Tell me the truth: which of these pills will really cure my illness?” The answer? “The last one.”

But we continue to see a problem. Around hospitals one hears about multi-drug-resistant tuberculosis, or multiply-resistant enterococcus or Vancomycin-Resistant Enterococcus or Methicillin-resistant Staphylococcus Aureus. We use acronyms for them, of course – MDRTB or MRE or VRE or MRSA – but we see them more and more often. Once these were rare conditions, virtually unknown outside center city hospitals and immune-suppressed populations. Not anymore.

These are circumstances when our commitment to market-oriented approaches to almost everything fall short. Antibiotics in general, and new drugs for these diseases in particular, just don’t have the return that other drugs do. The NPR story referred to medications that one takes for the rest of one’s life, like blood pressure or cholesterol drugs; or medications that have a high profile lifestyle attraction, like drugs to treat erectile dysfunction. These are very profitable, either because the market for them will be very steady, or because the demand of the market will bear a pretty high price. Antibiotics, on the other hand, are designed for limited use: once your body’s back in order you don’t need them; and there’s no glamour to the conditions they treat.

At the same time, the effects of our failure to pursue them will far outweigh the effects of either of the other two health issues I mentioned. This is not to downplay the potential value of stem-cell based treatments, or the importance of the morning after pill to a woman who fears a pregnancy that should not have happened. But neither is likely to affect as many people as better treatments for tuberculosis or whooping cough or salmonella or strep throat. Indeed, there has been a frightening resurgence of tuberculosis among HIV/AIDS victims abroad, and of whooping cough here at home. The potential public health benefits of new antibiotics should be important to every one of us, because every one of us is at risk of infection.

I am not in principle opposed to the market or to profit. However, this is one of those places where I think we as a society, and our leaders especially, demonstrate misplaced values. There are some roles that government must appropriately play because they affect the common welfare, and because without government’s action nobody else will. We need to call on our elected and appointed leaders to take on this burden, to fund this research. While I still believe for-profit health care is a sin, if it will get new drugs sooner to those who need them, I can live with a government-corporate partnership. But partnerships for new antibiotics and for other important but low-profit drugs will only come about if our political leaders express our political will to make it happen.

I have been known to say from the pulpit that I will believe this is a Christian nation when I see a social policy based on and thoroughly focused on service to “the least of these.” This should be an issue that really evokes that possibility; because in this case, “the least of these” may well include all of us.

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