The Center for Bioethics and Social Justice at Michigan State University is excited to welcome new faculty member M. Ariel Cascio, PhD, who starts in August. Cascio has an anthropology and neuroethics background, and their work is also oriented around research ethics, disability studies, and medical education.
Cascio received their PhD in anthropology from Case Western Reserve University in 2015. Their research has focused on ethical and social issues related to autism and neurodiversity more broadly. During their dissertation research, Cascio spent almost a year in Italy conducting ethnographic research with youth attending autism-focused services.
Most recently Cascio was an assistant professor at Central Michigan University College of Medicine. Previously they were a postdoctoral researcher at the Pragmatic Health Ethics Research Unit of the Institut de recherches cliniques de Montréal (IRCM), where they conducted a multi-national, multi-lingual survey study that investigated the preferences of autistic people and parents for different types of services, and collaborated with autistic people and other stakeholders to develop person-oriented research ethics suggestions for studies involving autistic people.
Fleck’s address on the ethical and legal issues of precision medicine is available to watch on YouTube, along with other content from the conference. Fleck’s address begins around the 11-minute mark of the video.
An audience of in-person and virtual conference attendees included lawyers, policy expects, and medical professionals. Many countries were represented among attendees, including the Netherlands, Spain, Portugal, Lithuania, Serbia, Italy, France, and Germany. This engaged audience was, in one sense, familiar to Fleck, who has long been collaborating with European researchers, including multiple groups from Erasmus University.
Fleck shared what he describes as a “wow” moment from his presentation:
“I had included a video link to an ad for the drug Opdivo (nivolumab) for non-small cell lung cancer. There are several variants of this ad, all with a common theme: “A Chance to Live Longer.” These ads have been shown (I am sure) thousands of times on U.S. TV. They clearly give the misleading impression that anyone taking this drug can expect significant life-prolongation (leaving it to the viewer’s imagination what that length of time might be). Most of the audience gasped and laughed as they watched the ad. Keep in mind that only in the U.S. and New Zealand may such drug ads appear on TV. So, this was a somewhat startling phenomenon for this audience.”
An hour of discussion followed Fleck’s lecture, exploring the complex questions related to drug costs and public policy. At the heart of these questions is Fleck’s definition of the “wicked problem”: no matter what choices we make, we are at risk of creating new problems that are just as bad, ethically and politically, as the allocation problem we are trying to solve.
Fleck said, “The other concept that was new to most people in the audience was “onco-exceptionalism,” the idea that cancer was morally special and deserving of something close to unlimited resources to provide any degree of benefit from treatment, no matter how small the benefit or how costly the benefit might be.”
Keynote lecture description
Metastatic cancer and costly precision medicines generate highly complex problems of health care justice. Targeted cancer therapies yield only very marginal gains in life expectancy for most patients at a very high cost, thereby threatening the just allocation of limited healthcare resources. Philosophers have high hopes for the utility of their theories of justice in addressing resource allocation challenges; however, none of these theories adequately address the “wicked” ethical problems that have resulted from these targeted therapies.
What we need instead, bioethicist Leonard M. Fleck argues, is a political conception of health care justice, following Rawls, and a fair and inclusive process of rational democratic deliberation governed by public reason. His account assumes that we have only limited healthcare resources to meet unlimited healthcare needs generated by emerging medical technologies. The primary ethical and political virtue of rational democratic deliberation is allowing citizens to fashion autonomously shared understandings of how to fairly address the complex problems of healthcare justice generated by precision medicine. While ideally just outcomes are a moral and political impossibility, “wicked” problems can metastasize if rationing decisions are made invisibly—in ways effectively hidden from those affected by those decisions. As Fleck demonstrates, a fair and inclusive process of democratic deliberation could make these “wicked” problems visible, and subject, to public reason.
The 2022-2023 Bioethics Public Seminar Series will conclude next month with a webinar from Center Assistant Professor Jennifer McCurdy, PhD, BSN, MH, HEC-C, on “How Brain Death Declarations Can Harm, and Why Legal Exemptions Should Be the Rule.” This virtual event is free to attend and open to all individuals.
According to U.S. law and The Uniform Determination of Death Act (UDDA), an individual can be declared dead by either cardiac or neurological criteria. The latter, known colloquially as brain death, allows a physician to withdraw patients from medical devices against the wishes of families and other surrogates. While once seemingly settled, the concept of death by neurological criteria has increasingly become a topic of controversy, both technically and philosophically.
This seminar will argue that the UDDA should make New Jersey-style legal exemptions to brain death declaration a national guideline, thus allowing individuals to claim a religious exemption when they disagree that brain death is, in fact, death. Why? Because the concept of brain death is based on a specific eurochristian worldview that is not held in common by many reasonable people in U.S. society. The imposition of those unshared worldviews on patients and their loved ones through force of law causes unjustified and avoidable trauma, furthers epistemic injustices, and generates distrust.
Jennifer L. McCurdy is an assistant professor in the Center for Bioethics and Social Justice within the Michigan State University College of Human Medicine. She is a clinical and social bioethicist and educator whose work focuses on understanding and eliminating racial and colonial injustices in contemporary health settings and communities. She currently engages medical students at MSU in curricula related to social context and ethics issues in healthcare. Her current research focuses on brain death policy, Black birthing family safety, and Indigenous representation in bioethics.
The 2022-2023 Bioethics Public Seminar Series continues this month with a webinar from Center Assistant Professor Megh Marathe, PhD, on “Expedient Classification: Diagnosis in Lived Experience and Medical Practice.” This virtual event is free to attend and open to all individuals. This event will be available as a live broadcast only.
This talk examines how doctors and patients distinguish between normal and pathological events through the case of epilepsy. Epilepsy is a chronic illness and disability characterized by recurrent and unpredictable seizures. Seizures are transient events during which people lose control over parts of body-mind function. The talk shows that the diagnostic boundary between seizure and non-seizure events is fluid, dynamic, and porous in lived experience and medical practice. Calling an event a seizure has consequences well beyond treatment, also affecting a patient’s financial stability, social participation, and life aspirations. Hence, doctors and patients take an expedient approach to classifying seizures, informally modifying the very definition of seizure to postpone or avoid severe consequences. Doing so enables doctors and patients to bend rigid classification schemes to suit the complex realities of people’s lives. This work advances scholarship on classification and expertise in information studies, science and technology studies, and disability studies.
Megh Marathe is an assistant professor in the Center for Bioethics and Social Justice in the College of Human Medicine and the Department of Media and Information in the College of Communication Arts and Sciences at Michigan State University. Marathe’s research seeks to foster inclusion in expert practices and technologies by centering the perspectives of marginalized people. They do this by studying the experiences and practices of multiple stakeholders – doctors and patients, citizens and civic officials – that is, laypeople and professionals, people who are marginalized as well as those in powerful positions, to generate critical theory and practical interventions for inclusive practice and technology design. Marathe adopts an ethnographic approach that is inflected by their computer science training and software industry experience.
The 2022-2023 Bioethics Public Seminar Series continues next month with a webinar from Center Assistant Professor Michelle T. Pham, PhD, on “Clinician Perspectives on the Potential of DBS for Pediatric Patients with Treatment-Resistant OCD.” This virtual event is free to attend and open to all individuals.
Wednesday, February 15, 2023 1:30-2:30 PM EST (UTC−05:00) Zoom webinar registration: bit.ly/bioethics-pham
The World Society for Stereotactic and Functional Neurosurgery has argued that at least two successful randomized controlled trials should be available before deep brain stimulation (DBS) treatment for a psychiatric disorder is considered “established.” DBS is currently offered to children ages 7 and older with refractory dystonia under an FDA-humanitarian device exemption. No randomized control trials were conducted – practitioners relied on evidence from DBS use in adults. In addition, accumulated research supports the safety and effectiveness of DBS for obsessive-compulsive disorder (OCD) in adults (Wu et al. 2021).
Approximately 10-20% of children with OCD have treatment-resistant presentations, so it is likely that there will be interest in offering DBS for some children (POTS 2004). Both ethical and empirical anticipatory work is needed to evaluate whether, and if so, under what conditions it might be appropriate to offer DBS in this context. This seminar will present qualitative data from semi-structured interviews with 24 clinicians with expertise in this area regarding: (a) acceptable levels of evidence to offer DBS in this patient population and (b) institutional policies or protocols needed to effectively provide care for them.
Michelle T. Pham is an assistant professor in the Center for Bioethics and Social Justice and the Department of Medicine in the Michigan State University College of Human Medicine. She conducts research in the interdisciplinary field of Neuroethics and connected issues in the Philosophy of Science. Some recent topics include promoting post-trial care for patient-participants in experimental brain implant studies and decision-making in the context of pediatric deep brain stimulation. Pham also researches ways to promote engagement with patient-participants who contribute to neuroscience and neurotechnology research; and she has raised the concern that patient-participants in these brain implant studies may be exploited.
Center Assistant Professor Jennifer McCurdy, PhD, BSN, MH, HEC-C, presented “Beyond Patient Behavior: Using Structural Competency to Create Health Equity” at the Michigan State Medical Society (MSMS) 26th Annual Conference on Bioethics: Contemporary Challenges in Clinical Bioethics in November. McCurdy’s presentation explored the social, political, and economic contexts that act as barriers to patients care and impede physicians’ ability to effectively treat them.
McCurdy asked those in attendance the following questions: Have you ever experienced moral distress or frustration associated with the medical “system?” Have you ever been unable to treat a patient for whom treatment exists, based on factors that are out of your control? What were those factors?
Using a case example, McCurdy discussed factors that determine the health status of an individual, such as behaviors, cultural norms, and biology. She also discussed social determinants of health, such as poverty, inadequate or no housing, lack of access to education, and lack of access to healthcare. McCurdy also outlined structural determinants of health, pointing to social structures, political structures and policy, and economic structures and policy—the “causes of the causes.”
How can physicians help? They are uniquely positioned in spaces that connect the medical world and the patients’ worlds, where they can observe recurrent barriers to care. They can work to create change at individual, interpersonal, and institutional levels. McCurdy also outlined how physicians’ involvement in the community, in policy, and in research can create structural change and therefore improve health equity.
Neff J, Holmes SM, Knight KR, Strong S, Thompson-Lastad A, McGuinness C, Duncan L, Saxena N, Harvey MJ, Langford A, Carey-Simms KL, Minahan SN, Satterwhite S, Ruppel C, Lee S, Walkover L, De Avila J, Lewis B, Matthews J, Nelson N. Structural Competency: Curriculum for Medical Students, Residents, and Interprofessional Teams on the Structural Factors That Produce Health Disparities. MedEdPORTAL. 2020 Mar 13;16:10888. doi: 10.15766/mep_2374-8265.10888. PMID: 32342010; PMCID: PMC7182045.
Gruen RL, Campbell EG, Blumenthal D. Public roles of US physicians: community participation, political involvement, and collective advocacy. JAMA. 2006 Nov 22;296(20):2467-75. doi: 10.1001/jama.296.20.2467. PMID: 17119143.
Megan Hoberg and Pamela Hoekwater of Legal Aid of Western Michigan presented at the December 1st Bioethics for Breakfast session, offering their insight and expertise on the topic “Medical Legal Partnerships: A Tool to Help Address the Social Determinants of Health.” Bioethics for Breakfast is generously sponsored by Hall, Render, Killian, Heath & Lyman.
The session provided an overview of medical legal partnerships (MLPs) and their impact, discussing the Legal Aid of Western Michigan (LAWM) partnership with Cherry Health—Michigan’s largest Federally Qualified Health Center that operates in six counties. Speakers Hoberg and Hoekwater defined a medical legal partnership as “an integration of lawyers into the health care setting to help clinicians, case managers, and social workers address structural problems at the root of so many health inequities.” MLPs are increasing in popularity across the U.S. and can result in patient success stories, provider satisfaction, and increased recognition and reputation from organizations in the community.
They explained that a big part of MLPs involves screening for issues that might not have an obvious legal component to them. They shared four legal aid practices that relate directly to different social determinants of health: family law, housing, public benefits, and individual rights. One component of an MLP is training the health organization’s work force to help identify potential legal needs in the patient setting.
A memorandum of understanding (MOU) between the relevant stakeholders is generally a starting point to form MLPs. Hoberg and Hoekwater shared that there are a variety of ways that MLPs are funded, including AmeriCorps/Equal Justice Works, private donors, law firms, bar associations, health organizations, and foundations. They shared the evolution of their partnership with Cherry Health, which started with a pilot program and now includes a full-time on-site attorney and community health worker. The MLP currently focuses on maternal infant health and the senior population. The MLP operates as a multi-step process that begins with a referral to the MLP team through the electronic health record which leads to a meeting between the patient and attorney.
Hoberg and Hoekwater also shared challenges associated with MLPs, such as stability of funding, balancing legal and medical ethics, systems integration, and internal communication. Challenges aside, they shared both quantitative and qualitative data that supports the positive impact of MLPs. One example of a specific impact is patients reporting improved mental health and lower levels of stress and anxiety.
It was clear during the question and answer potion that attendees were interested in learning more about how they can pursue forming MLPs at their organizations, and how they can help their patients receive the legal support they need.
Megan Hoberg is a Staff Attorney with Legal Aid of Western Michigan (LAWM). Previously, she worked as the Medical Legal Partnership Attorney, for the MLP LAWM maintains with Cherry Health. Megan’s perspective sheds light on how MLPs operate on a daily basis and the impact they produce for patient/client communities. Megan was drawn to MLPs during her time at Wayne State University Law School, when she served as a student attorney for The Legal Advocacy for People with Cancer Clinic and earned the 2020 Outstanding Clinical Student Team Award from the Clinical Legal Education Association (CLEA). Starting her career in healthcare and bioethics, working with MLPs and poverty law allows her to use her legal training to advance public health goals in an interdisciplinary setting. She is a member of the following organizations: State Bar of Michigan Professional Ethics Committee, Women Lawyers Association of Michigan, and American Society for Bioethics and Humanities.
Pamela Hoekwater serves as the Executive Director for Legal Aid of Western Michigan (LAWM). She has over 20 years’ experience in poverty law work since starting her legal career as a Staff Attorney in 2001 and has developed innovative partnerships with local agencies to integrate legal services in the community, including the YWCA, Goodwill Industries, and Hope Network. Having helped launch LAWM’s first medical legal partnership (MLP) in 2017, Pam holds a unique perspective and expertise as to the challenges of maintaining and advancing MLPs. Notably, she contributed to the formation of the Medical Legal Partnership with Cherry Health, which has been fully funded and staffed since 2019. Pam strives to advance social justice and equity through her participation/leadership in the following organizations: Resource Committee for Michigan Justice For All Commission, State Bar of Michigan Diversity and Inclusion Advisory Committee, Michigan State Planning Body, and Legal Services Association of Michigan.
Leonard M. Fleck, PhD, and Karen Smith, LMSW, PhD, HEC-C, presented at the October 13 Bioethics for Breakfast session, offering their insight and expertise on the topic “Demystifying End-of-Life Care.” Bioethics for Breakfast is generously sponsored by Hall, Render, Killian, Heath & Lyman. The presentation portion of the session was recorded and is available to watch on our website.
The State of Michigan has recently approved the MI POST (Michigan Physician Order for Scope of Treatment), which allows a patient and physician to have in place directions (orders) on care to go between levels of treatment. Such orders typically specify the kind of care a terminally ill patient would want or refuse in an emergency situation outside a hospital setting. Such orders are agreed to by a competent patient or their representative and the attending physician. A POST document is often part of a larger advance care planning document.
Most patients do not have an advance directive or a POST. What happens when that patient is actively dying and the attending physician believes a Do Not Attempt Resuscitation order (DNAR) is in the best interest of that patient? Should that decision by the physician require the written consent of the patient’s family for that DNAR order? And what are the consequences for the patient if the family cannot reach agreement? If you were that patient, what would you regard as the most reasonable course of action? How would you ensure your wishes are followed?
Presenters Fleck and Smith gave some background on what it means to have a natural death and a managed death, noting that the majority of Americans today die a managed death. Smith explained that durable power of attorney and MI POST are the two state-authorized methods for directing end-of-life wishes. Fleck asked attendees to consider the following questions: Are the policies and practices in place regarding terminally ill incapacitated patients good enough? Are they the best we can do? What might we do better? What do we see as the main deficiencies in current policy and practice?
The presentation also explored how policy can protect patients and prevent suffering at the end of life and presented multiple case examples regarding terminal care in the ICU. Discussion during the Q&A portion focused on family disagreements in the ICU, the value of healthcare literacy and common misconceptions that stem from popular culture, and what happens when the court system is involved with end-of-life decisions.
Varkey B. Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice. 2021;30:17-28. DOI: 10.1159/000509119. Free PubMed Central access.
About the speakers
Leonard M. Fleck, PhD, is a Professor in the Center for Bioethics and Social Justice and the Department of Philosophy at Michigan State University. Fleck’s interests focus on medical ethics, health care policy, priority-setting and rationing, and reproductive decision-making. He explores the role of community dialogue (rational democratic deliberation) in addressing controversial issues of ethics and public policy related to emerging genetic technologies. More recently, he has completed a book-length manuscript that addresses a number of ethical and policy issues related to precision medicine, primarily in a cancer treatment context. He also completed another book that addresses several contemporary issues related to bioethics and religion from a Rawlsian public reason perspective.
Karen Smith, LMSW, PhD, HEC-C, has been a member of hospital ethics committees for over 20 years. She is currently the Director of Ethics Integration for Henry Ford Health, a six-hospital system in metro Detroit. Smith publishes on issues related to clinical ethics the hospital setting. She specializes in death and dying issues and often works to educate the public on Advance Directive issues. She has been on the National Board for the Funeral Consumers Alliance which is a non-profit organization dedicated to providing the public education and advocacy related to after death needs.
The 2022-2023 Bioethics Public Seminar Series begins next month with a webinar from Center Professor Leonard M. Fleck, PhD, on “Precision Medicine and Distributive Justice: Wicked Problems for Democratic Deliberation.” This virtual event is free to attend and open to all individuals.
Metastatic cancer and costly precision medicines generate extremely complex problems of health care justice. Targeted cancer therapies yield only very marginal gains in life expectancy for most patients at very great cost, thereby threatening the just allocation of limited health care resources. Philosophic theories of justice cannot address adequately the “wicked” ethical problems associated with these targeted therapies. Following Rawls, Fleck argues for a political conception of health care justice, and a fair and inclusive process of democratic deliberation governed by public reason. The virtue of democratic deliberation is that citizens can fashion autonomously and publicly shared understandings to fairly address the complex problems of health care justice generated by precision medicine. “Wicked” problems can metastasize if rationing decisions are made invisibly. A fair and inclusive process of democratic deliberation can make these “wicked” problems visible, and subject, to fair public reason constraints. What constrained choices do you believe you would endorse with your fellow citizens as being “just enough”?
Leonard M. Fleck, PhD, is a professor in the Center for Bioethics and Social Justice and the Department of Philosophy at Michigan State University. Dr. Fleck’s interests focus on medical ethics, health care policy, priority-setting and rationing, and reproductive decision-making. He explores the role of community dialogue (rational democratic deliberation) in addressing controversial issues of ethics and public policy related to emerging genetic technologies. More recently, he has completed a book-length manuscript that addresses a number of ethical and policy issues related to precision medicine, primarily in a cancer treatment context. He also completed another book that addresses several contemporary issues related to bioethics and religion from a Rawlsian public reason perspective.
What are we willing to accept as limits on access to very expensive marginally beneficial healthcare in our society?
Center Professor Leonard M. Fleck’s latest book, Precision Medicine and Distributive Justice: Wicked Problems for Democratic Deliberation, is now available from Oxford University Press. Fleck’s work as a philosopher and medical ethicist has focused on health care policy, and the role of community dialogue in addressing controversial issues of ethics and public policy related to emerging genetic technologies.
In an interview about this book, Fleck spoke of beginning democratic deliberation work around 1980 as part of a research project regarding changes to the Medicare program. He described the importance of involving members of the community in conversations about what values and considerations should shape the kinds of limits they would be willing to live with in terms of accessing needed healthcare. That project, centered in an Indiana community, shaped his work moving forward. The interview that follows explores the importance of democratic deliberation regarding the use of targeted cancer therapies.
The following interview has been edited for length and clarity.
Who is the ideal audience of this book?
The ideal audience would be a broad segment of the public that needs to be aware of the kinds of challenges, the ethical and public policy challenges, that are associated with precision medicine. Its high cost and its marginal benefit.
How would you broadly define precision medicine?
Typically, precision medicine is defined as providing the right drug at the right time and the right dose for the right medical problem. Right now, mostly what we’re talking about is cancer, that is, metastatic cancer. What we’re talking about are the molecular features of a metastatic cancer that a particular individual has. The drugs that are used to attack that cancer are drugs that are designed for the very, very, very specific molecular features of a particular cancer. Some of those features get to be defined in really sharp terms. Researchers and physicians no longer talk about a stomach cancer or a lung cancer—I mean they they’ll use those terms, but the recognition is that the nature of the cancer, in terms of what we’re going to try to do about it from a therapeutic perspective, that’s going to be determined by the molecular signature of that cancer.
What is democratic deliberation, and why is it important? How does it apply to this topic of precision medicine and healthcare justice?
I always start off with what I call the “Just Caring” problem. What does it mean to be a just and caring society when we have only limited resources—money—to meet virtually unlimited healthcare needs? And that’s a very, very broad problem that applies to all of healthcare, certainly in the United States today. With regard to cancer, the issue is that these targeted cancer therapies, and the so-called immunotherapies which are among the targeted cancer therapies, are extraordinarily costly. They typically apply to relatively small groups of patients, measurable in a few thousand rather than one hundred thousand. For the vast majority of these patients, receiving one of these very expensive drugs is only going to yield extra months of life, if that, as opposed to a lot of extra years.
So, if we had a $100,000 drug and this was going to give somebody three extra years of life, my guess is that most of us, democratic deliberators charged with determining how to spend our money on a whole range of healthcare interventions, including, of course, cancer, would say it’s a lot of money, but if we’re giving somebody three extra years, we ought to do that. And we ought to do that, we might say, because we think about, what are we spending now for purposes of giving a patient with HIV an extra year of life? A patient on a four-drug combination? The answer there would be $35,000 a year. And if we spend a $100,000 to give somebody three extra years of life, then that’s $33,000 a year. So it seems like if we’re spending money for the HIV positive patient at that level, we ought to be willing to spend that same amount of money to help cancer patients.
However, things are a lot more complicated than that simple example would suggest. So, in the case of cancer, one of the basic problems that I didn’t make perfectly clear in my earlier remarks is that even though I talked about a molecular feature of a cancer that is usually described as the driver of that metastatic cancer, and that is the target one of the targeted therapies, the fact of the matter is that in metastatic cancer there are going to typically be multiple drivers of a cancer. Most of them will be suppressed by the dominant driver. What happens in practice is that we’ve identified the dominant driver of the cancer, we give the individual a drug to kill that dominant driver, which it successfully does. And then another new driver emerges within that tumor, and then the tumor continues to grow, the cancer progresses. Now we may have another drug for that new driver, which will have roughly the same effect. It’ll kill that new driver and make room for yet another driver. But now, then, we’re providing to individuals several drugs in a row that have costs of $100,000 or $200,000 each. So, we’re spending a lot more money for a lot less good for these cancer patients. And so, the question for democratic deliberation is, what do we owe, under what particular circumstances, as a matter of what a just and caring society ought to be, to patients with metastatic cancer for whom there are these very expensive drugs that are only going to yield, for most patients, marginal benefit?
What I would ask an audience to imagine, when I’m working with an audience of individuals from the community, is that everybody in that room is probably very healthy. They have no idea what their future health vulnerabilities might be. Some people might say, well, we’ve got heart disease in the family, or some family history suggests cancer, but there’s still lots and lots of other health problems that you could have that could be deadly. The question is, if you don’t want to spend all your money on healthcare, and you don’t want to spend everybody else’s money on healthcare, then, collectively, what would you see as being reasonable investments of limited healthcare resources for addressing healthcare needs? Cancer needs, heart needs, Alzheimer’s disease needs, diabetic needs, psychiatric needs, needs associated with various kinds of disability. When you, in a thoughtful and objective way, try to consider the whole range of healthcare needs, where should we invest the limited dollars that we’re willing to provide? Right now, it’s 18% of our gross domestic product, roughly $4.1 trillion. Where are we willing to invest those dollars?
What led you to work that focuses on precision medicine? Was it natural from the other health policy work you have done, specifically work on allocating resources?
It was related both to allocating resources, because the cost of these drugs just leapt out at me, starting roughly in around 2010 or so. But the other thing was that I had been looking at a whole range of ethics and policy issues related to emerging genetic technologies. This was one of the newer elements associated with these emerging genetic technologies. This was a product of the Human Genome Project. Plus, the research that had been going on with regard to cancer, as researchers began to understand the extent to which cancer is this extraordinarily complex disease, that there’s not just sort of one or two or three drivers of these cancers. That there are different biological features of the cancer that are responsible for the cancer being so vigorous in multiplying. In brief, there’s that combination of the cost of these drugs and what that would do to distort the just allocation of health resources in our society, and the genetic features of these cancers that turned out to be so extraordinary genetically complex.
Something that strikes me, discussing these very expensive targeted therapies, is where does palliative care fit into the discussion of precision medicine?
For oncologists who are treating patients, for patients who have read something about precision medicine, for patients who have looked at some of the ads that are associated with precision medicine that have been on television, it’s very difficult to convince any of those patients that palliative care is something that they needed to give serious consideration to. Because it looked like these drugs could give them some very significant extensions of their life. And, of course, the fact of the matter is that there’s some percentage of patients who will get one or two or three extra years of life. There’s a teeny tiny percentage of patients who we call super responders, who might get seven, eight, ten extra years of life or more. At the moment we have no way of identifying before the fact how particular patients are going to respond to these drugs.
What happens is that patients imagine to themselves, I could be that person. Somebody is going to be a super responder, just like somebody ultimately wins that half a billion dollar lottery prize. How do I know it’s not me if I don’t buy a lottery ticket? How do I know it’s not me if I don’t take on this targeted cancer therapy? And if the first therapy doesn’t work, I heard that there’s a second and a third. And so as long as they seem to be doing something by way of controlling my cancer, of course I want that. I don’t want palliative care. So that’s sort of the psychological logic behind the reluctance of both patients and oncologists to recommend palliative care before it is just absolutely clear that nothing else is going to work.
What is one overall takeaway someone should get from this book? What is the question you want folks to continue thinking about?
What are we willing to accept as limits on access to very expensive marginally beneficial healthcare in our society? I want readers to think about the just caring problem, which is an extraordinarily complex problem. I’ve spent 50 years of my life thinking about this issue. And it’s only grown and become more complex over those 50 years, because of all the emerging life prolonging medical technologies that have come to be. Not just with regard to cancer, but with regard to heart disease, liver disease, lung disease, diabetes, and every other area of medicine that we care to name.
I’d like to add that ideally, ethically, I think we’re inclined to say, if we have a somewhat costly life prolonging care that’s effective, then everybody with the relevant need ought to have access to that if we are a just and caring society. If somebody has an inflamed appendix that is life threatening if they don’t receive the necessary surgery, then they ought to receive that surgery, whether they’re rich or poor, insured or uninsured. They ought not to be allowed to die. You will get, I think, very broad agreement in our society that that’s a just and reasonable kind of moral commitment we ought to make. It gets more difficult, though, to make that commitment when it comes to these extraordinarily expensive cancer drugs. And part of the problem is that in the United States probably no more than half of us are employed at places where we’re provided with very comprehensive health insurance, and where we’re not responsible for paying very much of the cost of our healthcare. But for the other half of the population who typically are working in lower wage jobs, who may be provided with some health insurance but it’s very marginal, it’s bare bones insurance. It’s the sort of insurance that requires that individuals pay 30 or 40% of the cost of these cancer drugs. And, of course, that’s impossible for individuals making $15, $20, $25, even $30 an hour. For a $150,000 drug, they cannot pay $30,000, and so they don’t get it. Nevertheless, they are paying through taxes, and through their insurance premiums, for others who would have access to these drugs. So that’s one of the fundamental inequities in our society, and the targeted cancer therapies make that inequity, I think, more visible. It doesn’t seem as if, as a society, we’re willing to address that challenge. However, that is one of the preeminent ethical challenges that must be addressed if we are to be a just and caring society.