Health Care and Social Justice: Just Take Two Aspirin for Your Tumor If You Cannot Afford Your Cancer Care

Comments open through October 24

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Leonard Fleck, PhD

Dr. Stanley Goldfarb is the former Associate Dean of Curriculum at the University of Pennsylvania Perelman School of Medicine. In a recent Wall Street Journal opinion piece, “Take Two Aspirin and Call Me by My Pronouns,” he complained that curricula in medical schools “are increasingly focused on social justice rather than treating illness.” He goes on to say, “A new wave of educational specialists is increasingly influencing medical education. They emphasize ‘social justice’ that is related to health care only tangentially.” Really? Only tangentially?

Readers will recall Dr. Mona Hanna-Attisha, a pediatrician in Flint, Michigan. She had discovered elevated lead levels in many of her pediatric patients. She could have “stayed in her lane,” provided chelation therapy, hoped for the best, and gone home for dinner. If this is what we would have taught her during her medical education, we would have been complicit in suborning a major injustice.

Dr. Hanna-Attisha did the necessary background research, discovered that public officials had switched the source of Flint’s drinking water to save money, which, in turn, resulted in lead being leached into the drinking water. She brought her case to the media and vigorously advocated (successfully) for correcting this health hazard. She did this for the sake of the children in Flint, many not yet born. This was not tangential to her role as a physician; this was integral and essential. This was a matter of social justice. This was part of her medical education in the College of Human Medicine.

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Image description: Dr. Mona Hanna-Attisha is seated at a table smiling. Image source: University of Michigan School for Environment and Sustainability/Flickr

The practice of medicine today is suffused with social justice challenges. As we explain to our first-year medical students, the clinic is not an island of “pure caring,” isolated from the injustices that are pervasive in our health care system and governing policies. Those injustices frequently seep into clinical practice through the hands of physicians who, no doubt, see themselves as just and caring practitioners. This may sound like hyperbole, but I ask you to consider the evidence.

For the past forty years the dominant demand in health policy has been for health care cost containment. I will remind the reader that last year in the United States we spent $3.65 trillion on health care, roughly 18% of our GDP, compared to 11% of GDP in most European nations. If we ask who is responsible for spending more than 70% of those dollars, the short answer is that physicians in the clinic are the responsible agents. Physicians decide whether a patient needs surgery, which drugs to prescribe, what diagnostic tests are necessary, how much home care is needed, and so on. Consequently, if a focal point is needed for controlling health care costs, it will be physicians.

Note that cost control can be a matter of justice or injustice. In either case, physicians will have to be mindful of the justice-relevant consequences of their diagnostic or therapeutic choices. In the 1990s a number of managed care plans used “at risk” reimbursement to elicit more cost-conscious physician clinical behavior. In some cases, as much as 30% of a physician’s income could be “at risk” if they ordered too many tests. They could also earn 30% bonuses if they were especially stingy in their use of tests. Patients knew nothing of these arrangements. Income risks and opportunities such as those could readily shape physician behavior in ways that were less than just. Whether physician judgment in these circumstances would be corrupted would depend upon whether in their medical education they had had the opportunity to reflect upon such future challenges (as opposed to thoughtlessly accepting such practices as “this is the way medicine is practiced today.”)

Putting physician income at risk to control costs related to patient care is crude and obvious. More problematic are the subtle and invisible ways in which physicians control costs justly or unjustly. For example, a patient demands an MRI to rule out brain cancer when a physician is medically certain these are tension headaches. But the physician authorizes the MRI because “insurance will pay.”

If thousands of physicians are indifferent to authorizing such unnecessary care, then the costs of health insurance to employers increase. For employers at the economic margins, that cost increase may mean dropping health insurance as a benefit, thereby adding those employees to the ranks of the uninsured. From the perspective of any individual physician, this is a very remote, invisible consequence of their decisions that creates an injustice. Medical students need to know this to practice medicine justly.

Other employers will change insurance coverage to reduce their costs. They will require their employees to accept insurance with $5000 front-end deductibles. Financially less well-off workers will deny themselves that unnecessary MRI (no injustice there), but they will also deny themselves medically necessary diagnostic procedures (sometimes with deadly consequences) by not even walking into a physician’s office. Why, physicians might ask, should they as physicians be responsible for those bad decisions by patients; there was nothing to diagnose in the examining room. But maybe there was something to diagnose in society? This is sounding a bit more like the situation in Flint. Non-physicians made cost control decisions but counted on physicians to see such decisions as “merely tangential” to the practice of medicine, nothing that should concern them.

Precision medicine has generated more than 90 FDA approved genetically-targeted cancer drugs with annual costs of more than $100,000. These drugs are used with patients with metastatic disease. The vast majority of these patients will gain no more than extra months of life from these drugs, not extra years (though clever media campaigns create a very different impression). For most workers, their health plan will require a 20-30% co-pay for these drugs, which is unaffordable for most workers. Financially well-off managers and executives will be able to afford those co-pays, which means that workers who could not afford the co-pays will have contributed through their premiums to subsidizing that other 70-80% for the well-off. Is that fair? Is that just?

Should physicians caring for these patients silently acquiesce to these insurance arrangements as “too tangential” to medical practice, too far removed from the clinic? Should we, as teachers of future physicians, also silently acquiesce so that more curricular time can be allocated to understanding the mechanisms of action of the next 90 FDA approved targeted cancer therapies? WWHAD: What Would Dr. Hanna-Attisha Do?

Leonard Fleck photoLeonard M. Fleck, PhD, is Acting Director and Professor in the Center for Ethics and Humanities in the Life Sciences and Professor in the Department of Philosophy at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 24, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Fleck: Medicare For All: This Is Going to HurtGreed Is God: The Divine Right to Avaricious Drug PricingGene Editing: God’s Will or God’s Won’t

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Listen: Ethics and Policy Issues of Targeted Cancer Therapies

No Easy Answers in Bioethics logoNo Easy Answers in Bioethics Episode 16

What kinds of challenges currently exist within precision medicine? This episode focuses specifically on targeted cancer therapies, featuring a discussion between Center Professor and Acting Director Dr. Len Fleck and College of Osteopathic Medicine student Stephanie Mackenzie. Dr. Fleck discusses ethics, economic, medical, and health policy issues related to these high-cost therapies. Additionally, he provides insight into how U.S. pricing models for these therapies compare with other countries.

Ways to Listen

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: “While We Walk (2004)” by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License. Full episode transcript available.

About: No Easy Answers in Bioethics is a podcast series from the Center for Ethics and Humanities in the Life Sciences in the Michigan State University College of Human Medicine. Each month Center for Ethics faculty and their collaborators discuss their ongoing work and research across many areas of bioethics. Episodes are hosted by H-Net: Humanities and Social Sciences Online.

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Bioethics for Breakfast: Medicare for All: What Should That Mean?

Bioethics for Breakfast Seminars in Medicine, Law and SocietyStacey Hettiger and Rick Murdock presented at the September 26th Bioethics for Breakfast event, offering perspectives and insight on the topic “Medicare for All: What Should That Mean?”

“Medicare for All” has become a contentious political slogan. Advocates for various versions of the slogan want to see everyone have access to needed and affordable health care. Critics see all versions of the slogan as unaffordable and hostile to individual liberty. Is compromise possible? Can we have some level of affordable health care for everyone in our society? Can this be accomplished in ways that are congruent with our most fundamental political values? Event speakers addressed these questions and more, inviting response and discussion from those in attendance.

This year’s Bioethics for Breakfast series centers on the theme “Is There a Cure for Our Sick Health Care System?”

About the Speakers

Stacey Hettiger
Stacey Hettiger is Director of Medical and Regulatory Policy at Michigan State Medical Society. Her responsibilities include developing materials, programming, and member communications in the areas of legal and regulatory compliance and State and Federal quality initiatives. This includes advocacy and outreach on issues affecting the delivery of health care such as HIPAA, physician payment models and incentives, and practice transformation. Prior to joining MSMS, Stacey worked for twenty years in the Michigan State Legislature.

Rick Murdock
Rick Murdock retired from the Michigan Association of Health Plans in 2017 after 12 years as executive director, and has since been consulting with the MAHP Foundation to coordinate the Michigan ACE (adverse childhood experiences) Initiative. Prior to joining MAHP, he spent three years working in the Michigan legislature, followed by 18 years in the State Budget Office (mental health and Medicaid and health planning). Additionally he spent 6 years in Medicaid administering the Medicaid managed care program. He has a master’s degree in public health from the University of Michigan School of Public Health.

About Bioethics for Breakfast:
In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
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Public Health Crisis Warrants Liberty Restrictions

Bioethics in the News logoThis post is a part of our Bioethics in the News series

By Parker Crutchfield, PhD

Preventing Harm
Suppose your colleague was diagnosed with tuberculosis on Friday but tried to come into work on the following Monday. You would be right to call local public health officials, and they would be warranted in isolating him. Now suppose instead that he was diagnosed with lung cancer on Friday but came into work Monday. You would be wrong to call local public health officials and they would be wrong to isolate him. When a person’s health or behavior are a threat to others’ well-being, there is greater moral justification for restricting the liberties of that person. This is just the converse of Mill’s Harm Principle, which states that the only time it is permissible to restrict a person’s actions is when those actions threaten to harm another person.

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Image description: A dry and cracked river bed in Sri Lanka. Image source: Bioversity International/S.Landersz/Flickr

Recently, the Australian Medical Association declared climate change a threat to the public’s health. This comes after a similar declaration was backed by organizations such as the American Medical Association, the American College of Physicians, the American Academy of Pediatrics, and the American Lung Association. Climate change is a health emergency that threatens the health and well-being of the public. Just as your colleague is a threat to the health and well-being of those around him, climate change is a threat to the public’s health and well-being. Thus, Mill’s Harm Principle applies—in principle it is permissible to restrict liberties to prevent the harm that ensues from climate change.

Public Health Ethics
When your colleague sees his oncologist about his lung cancer, the physician likely prioritizes the patient’s well-being. But public health ethics takes a more utilitarian approach: the individual’s interests are secondary to the greater good. Instead of balancing values such as patient autonomy and the physician’s judgment about what is most medically appropriate, public health ethics primarily balances liberty, equality, and utility (benefit). This to say that, for example, one person’s liberty may be justifiably restricted so that greater utility to the public may be achieved, or that it may be permissible to sacrifice some utility so that everyone can be subjected to the same treatment. Other values such as transparency or solidarity may be incorporated secondarily.

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Image description: A large stack billows dense smoke into the air that appears pink against blue sky. Image source: Billy Wilson/Flickr

Viewing climate change through the lens of public health ethics, which interventions best balance liberty, equality, and utility? There is significant disutility of not doing anything—there will be incalculable harm to very many people. The cost of doing nothing is so high that there is almost no benefit we might achieve presently that could outweigh it. Trading the harms we will suffer by doing nothing for the benefit we might achieve by doing nothing is a bad deal for us and a much worse deal for the next generation.

It is not commonly noted, but the same could be said for liberty—by doing nothing we trade future liberties for present ones. If we want to promote liberty in the future, we need to restrict it now. Currently those who are best positioned to intervene on climate change enjoy an extensive scheme of liberties. We can cool our houses to 68 degrees in the middle of summer; we can travel by jet to anywhere we might want to go; we can preserve our food in disposable plastic containers; we can mostly go outside without fear of catching a mosquito-borne illness; we can even use plastic rather than paper straws!

Inaction and Liberty
If we do nothing in the name of preserving these liberties, we stand to lose much more. It’s pointless to travel by jet to a place that’s underwater or that’s so hot it could kill you, to say nothing of the prospects of actually living there. When the changing climate displaces those living in New Orleans, Phoenix, Miami, the mid-Atlantic, or anywhere else in the world that will be uninhabitable, those people have to go elsewhere, increasing population density in those areas. Cooling our residences and workplaces may be prohibitively expensive, along with refrigerating our food, manufacturing plastic straws, or going outside in shorts and a t-shirt. Such effects will only exacerbate social inequalities.

Or consider the worst-case scenario, one in which climate change exerts too much pressure on governments, undermining their ability to uphold the laws that democracies have agreed to, such as laws prohibiting taking another person’s stuff. In such a scenario one’s scheme of liberties might be as extensive as it could possibly be. But in that case life is solitary, poor, nasty, brutish, and short—all conditions that make it impossible to exercise those liberties and that significantly limit one’s self-determination. The dead have no liberties. For people who want to preserve and promote individual liberty, it makes sense to intervene now.

To What Extent?
If ethical intervention upon threats to the public’s health requires finding the best balance of liberty, equality, and utility, then we have justification to restrict present liberties. Doing so not only promotes greater future utility, but it also promotes greater future liberties. I have not addressed equality, but as things stand now doing nothing will exacerbate social inequalities. But to what extent can present liberties be restricted?

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Image description: two brown and white cows are shown within a crowded group of cattle. Image source: Beatrice Murch/Flickr

Given the severity of the threat climate change presents to future liberties, it may be reasonable to prohibit air travel, driving vehicles that fail to meet certain emissions standards, eating beef, or even using plastic straws and incandescent light bulbs.

I mention above that there are other values that may be considered. If it is permissible for states—in the name of public health—to restrict present liberties to promote future liberties, how can they do so transparently? Does restricting present liberties promote or undermine solidarity among the population? If restricting present liberties undermines solidarity, does it do so to the degree necessary to outweigh the promotion of future liberty, equality, and utility?

parker-crutchfield-cropParker Crutchfield, PhD, is Associate Professor in the Program in Medical Ethics, Humanities, and Law at the Western Michigan University Homer Stryker M.D. School of Medicine, where he teaches medical ethics and provides ethics consultation. His research interests in bioethics include the epistemology of bioethics and the ethics of enhancement, gene editing, and research.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, October 10, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

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Dr. Laura Cabrera and co-authors published in ‘Nature Biomedical Engineering’

Laura Cabrera photoCenter Assistant Professor Dr. Laura Cabrera and co-authors Charles Sadle and Dr. Erin Purcell have an article in the August 2019 issue of Nature Biomedical Engineering. In “Neuroethical considerations of high-density electrode arrays,” the authors state that “the development of implantable electrode arrays that broadly and seamlessly integrate with brain tissue will require innovation that responsibly considers clinically relevant neuroethical concerns.”

The full text is available online via Nature (MSU Library or other institutional access may be required to view this article).

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Exploring life with a spinal cord injury

Spinal Cord Injury: Everything You Wanted to Know But Were Afraid to Ask

Mark Van Linden photo

Mark Van Linden, MSA

Event Flyer

Look at him zip around in that wheelchair. He is so independent and inspirational. But I wonder how he goes to the bathroom, if he’s really as happy as he seems, does he have sex, how does that work, is he in pain, does he work? What are the health problems he has to deal with, what are medical expenses? There are many dimensions to a happy and healthy life, and everyone would agree that life is complicated. But when multiplied by a spinal cord injury (SCI), the complexity of life can be off the charts—what we used to take for granted becomes a monumental challenge. This talk will explore life with SCI from a first-person perspective.

October 16 calendar iconJoin us for Mark Van Linden’s lecture on Wednesday, October 16, 2019 from noon until 1 pm in person or online.

Mark Van Linden grew up in Lansing, MI and had a very stable and nurturing childhood. Raised by his Dad, Mark attended a private high school, played basketball in college, graduated with a BS in manufacturing, and started out in his career as a manufacturing engineer in the automotive industry. His career was going very well; seemingly right on schedule he met a girl, got married, started a family, and the American Dream was well on its way to reality. Then in 2009, it was discovered that he had an aortic aneurysm, and the required surgery would replace his entire aorta from the arch to the femoral artery. During that surgery, at age 39 with two kids ages 2 and 4, he became paralyzed from the waist down. Everything he knew was now turned upside-down, and a new life was about to begin.

In person: This lecture will take place in C102 Patenge Room in East Fee Hall on MSU’s East Lansing campus. Feel free to bring your lunch! Beverages and light snacks will be provided.

Online: Here are some instructions for your first time joining the webinar, or if you have attended or viewed them before, go to the meeting!

Can’t make it? All webinars are recorded! Visit our archive of recorded lecturesTo receive reminders before each webinar, please subscribe to our mailing list.

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Should we trust giant tech companies and entrepreneurs with reading our brains?

This post is a part of our Bioethics in the News seriesBioethics-in-the-News-logo

By Laura Cabrera, PhD

The search for a brain device capable of capturing recordings from thousands of neurons has been a primary goal of the government-sponsored BRAIN initiative. To succeed would require developing flexible materials for the electrodes, miniaturization of the electronics and fully wireless interaction. Yet this past summer, it was corporately funded Facebook and Elon Musk’s Neuralink that stepped forward with announcements regarding their respective technological investment to access and read our human brains.

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Image description: A black and white graphic of a person’s head with an electric plug extending out of the brain and back of the head. Image source: Gordon Johnson from Pixabay

Elon Musk, the eccentric technology entrepreneur and CEO of Tesla and Space X, made a big announcement while at the California Academy of Sciences. This time it was not about commercial space travel or plans to revolutionize city driving. Instead Musk presented advances on a product under development at his company Neuralink. The product features a sophisticated neural implant which aims to record the activities of thousands of neurons in the brain, and write signals back into the brain to provide sensory feedback. Musk mentioned that this technology would be available to humans as early as next year.

Mark Zuckerberg’s Facebook is also funding brain research to develop a non-invasive wearable device that would allow people to type by simply imagining that they are talking. The company plans to demonstrate a prototype system by the end of the year.

These two corporate announcements raise important questions. Should we be concerned about the introduction of brain devices that have the capacity to read thousands of neurons and then send signals to our brains? The initial goal for both products is medical, to help paralyzed individuals use their thoughts to control a computer or smartphone, or in the case of Facebook to help those with disabling speech impairments. However, these products also are considered to be of interest to healthy individuals who might wish to “interact with today’s VR systems and tomorrow’s AR glasses.” Musk shared his vision to enable humans to “merge” with Artificial Intelligence (AI), enhancing them to reach superhuman intelligence levels.

Time will tell whether or not these grand visions, that currently veer into science fiction, will be matched by scientific progress. However, if they ultimately deliver on their promise, the products could change the lives of those affected by paralysis and other physical disabilities. Yet, if embraced by healthy individuals such technologies could radically transform what it means to be human. There are of course sound reasons to remain skeptical that they will be used. First off there are safety issues to be considered when implanting electrodes in the brain, including damage to the vasculature surrounding the implant as well as tissue response surrounding the device. And that is what is currently known about inserting brain-computer interfaces with only a couple of electrode channels. Consider what might happen with thousands of electrodes. There remain simply too many unknowns to endorse this intervention for human use in the next year or so. There also are salient issues regarding brain data collection, storage, and use, including concerns connected to privacy and ownership.

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Image description: a black and grey illustration of a brain in two halves, one resembling a computer motherboard, the other containing abstract swirls and circles. Image source: Seanbatty from Pixabay

Beyond these concerns, we have to think about what happens when such developments are spearheaded by private companies. Privately funded development is at odds with the slow, careful approach to innovation that most medical developments rely upon, where human research subject regulations and safety measures are clear. It is the “move fast and break things” pace that energizes start-up companies and Silicon Valley entrepreneurs. The big swings at the heart of these entrepreneurial tech companies also bring considerable risks. When addressing sophisticated brain interfaces, the stakes are quite high. These products bring to mind scenarios from Black Mirror, a program that prompts a host of modern anxieties about technology. On one hand, the possibility of having a brain implant that allows hands-free device interaction seems exciting, but consider the level of information we then would be giving to these companies. It is one thing to track how individuals react to a social media post by clicking whether they “like” it or not, or by how many times it has been shared. It is another thing altogether to capture which parts of the brain are being activated without us having clicked anything. Can those companies be trusted with a direct window to our thoughts, especially when they have a questionable track record when it comes to transparency and accountability? Consider how long it took for Facebook to start addressing the use of customer’s personal information. It remains unclear just how much financial support Facebook is providing to its academic partners, or whether or not volunteers are aware of Facebook’s involvement in the funding-related research.

The U.S. Food and Drug Administration as well as academic partners to these enterprises may act as a moderating force on the tech industry, yet recent examples suggest that those kinds of checks and balances oftentimes fail. Thus, when we hear about developments by companies such as Facebook and Neuralink trying to access the thoughts in our brains, we need to hold on to a healthy skepticism and continue to pose important challenging questions.

Laura Cabrera photoLaura Cabrera, PhD, is an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Translational Neuroscience at Michigan State University.

Join the discussion! Your comments and responses to this commentary are welcomed. The author will respond to all comments made by Thursday, September 26, 2019. With your participation, we hope to create discussions rich with insights from diverse perspectives.

You must provide your name and email address to leave a comment. Your email address will not be made public.

More Bioethics in the News from Dr. Cabrera: Should we improve our memory with direct brain stimulation?Can brain scans spot criminal intent?Forgetting about fear: A neuroethics perspective

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