This post is the first in a new series of entries written for my Patient, Physician, and Society class on the Profession of Medicine. The syllabus says “The Profession of Medicine (POM) is about the identity of the profession itself: what it is, what it should be, and how you might work to close any gaps you see between the two. The key questions of POM remain constant: ‘What should the profession do?’ and ‘How will you practice medicine?’
Resource Allocation
When I read these articles criticizing the culture of modern medicine for spending way too much on (in these articles, it’s usually excessive) care for one patient when the same money could be spent to cure a multitude of patients, I wonder if these are the discussions of medical ethics boards around the world. As far as I know, America is the only country (or maybe one of a select few) that puts so much emphasis on individualism. Here in the States, it’s all about me, what I can do to better my situation, and the size of the crowd I can gather to promote my agenda. It’s not too difficult, then, to understand why medical ethics boards in the United States focus so much of their efforts on discussions of brain death, organ transplantation, end of life care, and other issues that center mainly on the individual patient at hand.
But what kinds of questions would an ethics board in, say, Europe, ask? I would imagine that if their community hospitals are responsible for the health of the entire community that they serve, rather than only the patients who walk through their doors, resource allocation would be much higher on their list of priorities. The same tear-jerking stories of patients dying while waiting for heart transplants that make the front pages of newspapers here may be dismissed there without much discussion. Why? Because they would understand that when the health of the community is your chief responsibility, delivering vaccines to prevent the outbreak of disease in the community would easily outweigh one procedure that could add 10 years to the life of one patient.
I guess, then, that this is what they mean when they say physicians are often at odds with public health. After all, if the system is trying to take away a life-saving heart transplant from your patient, someone whose life you’ve been entrusted to save, why wouldn’t you fight as hard as you can for that heart? How hard would it be to be the one to tell the patient “I’m sorry, but you’re not going to get your heart transplant because we need to vaccinate a thousand kids?”
I really don’t know what to say about what seems at times to be diametrically opposing views on health care. As an MD/MPH student, I feel like I have competing interests in this debate. The physician side of me would refuse to accept no for an answer when it came to getting that heart transplant. But the public health side of me would argue that the patient has a high chance of dying of complications or of rejecting the heart altogether, whereas those vaccines could save hundreds of lives as well as enough money to provide for the next few heart transplant patients that walk through the doors.
Maybe it really is just about a perspective that needs to be switched. Should we really shame states like Oregon that provide health care for hundreds of thousands of uninsured patients instead of paying for a few organ transplants? Why aren’t we praising them for being cost-effective, lowering the cost burden for the rest of us, while at the same time providing coverage to so many people who really need it? But what about the sanctity of the patient’s life, the duty to “apply, for the benefit of the sick, all measures that are required?”
I hope being MD/MPH doesn’t end up making me bipolar.
Lastly, a couple of questions to address things of interest I found in the readings:
In response to a passage in Paul Farmer’s “New Malaise” on how compared to a few decades ago, modern medicine “can at last offer the sick truly revolutionary new therapies,” while at the same time opening up a whole new can of worms related to equity:
Much of these advances in medicine, especially in therapeutics like antibiotics, are fueled by industry, which itself is in this business to make money. It has been said that if prescription drug prices fell to a point where they would be affordable for everyone around the world, pharmaceutical companies would have no incentive to invest the large amounts of money into R&D that is necessary to develop these drugs.
The question, then, is would we be better off in a world where the price of progress is inequality (the high cost of prescription drugs precludes entire populations from access to them)? Or would we be better off in a world where the price of equality is progress (drugs would be accessible to everyone, but few institutions would be interested/devoted to discovering new therapies – and we would have fewer of these revolutionary new drugs)?
In response to the paragraph on how US physicians participate in state-sponsored executions, ostensibly against the oath they took to do no harm:
Assuming that state-sponsored executions won’t be going away anytime soon, would it be better for physicians to be hands-off, claiming that participation would be counter to the professional oath they took? Or would it be better for physicians to participate, claiming that even more suffering would result if physicians did not take action (in the absence of physicians, prison wardens – most of whom have no medical training – commonly perform the execution)?
