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Rapid Responses: Rapid Responses published:
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Test of ethics
- J.David Leopold (7 November 2005)
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Market Altruism
- Andrew J Ashworth (7 November 2005)
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Re: Test of ethics
- Rosetta Manaszewicz (7 November 2005)
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How can we turn cancer into a chronic disease that we can afford to treat?
- Michael P. Brown, Ian N. Olver (2 February 2006)
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J.David Leopold, Consultant Physician Cwmrhydycwrw Cottage Hospital, Swansea SA6 4NL
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Sir, Your paper is both important and timely. Its conclusions will recieve widespread support, including mine. Wherever one looks there is growing tension between the best treatment and the economic imperative. It is no longer possible for Doctors to ignore the pervasive conflict between Ethics and Employer, Patient and Politician, God and Mammon. However, one might question the "test" used as a yardstick of ethical awareness. Whatever a "Reasonable Doctor" might do, or believe, is not, in ethical terms,immediately relevant at the moment of an individual doctor's decision regarding the giving of information. He may "reasonably" be expected to pay heed to His Own guess as to the opinion of such a Reasonable Doctor, but his ethical position can only be based upon his own individual opinion of the merits of a drug. We often express this to mean the truthful response to the question "what would I want done for my wife etc if I could afford to pay, or money were no object?" The ethical Doctor would then be one who advises his patient as he would his wife. The opinions of the "Reasonable Doctor" are inevitably and, in this context, confusingly disputatious...as many Reasonable opinions might exist as Doctors asked! Kind regards
Competing interests: None declared |
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Andrew J Ashworth, GP Principal Davidson's Mains Medical Centre, 5 Quality St, Edinburgh, EH4 5BP
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The three factors cited (Beneficence, Respect for Autonomy and Distributive Justice) provide an excellent framework within the debate on drug costs and availability but they do not take into account the effect of individual prescribing decisions on drug costs and availability. Where pharmaceutical markets are led by paternalistic healthcare collectives prescribing according to published evidence the effect is minimal, where patients make their own choices according to perceived benefits, a free market of individuals develops. Development of a free market with innovation, competition and subsequent improvements in costs and availability occur as a consequence of individual prescribing decisions; there is a social dimension to permitting poorer patients to choose to make greater personal sacrifices to drive the market. Free markets can be restricted by large purchasing monopolies such as large supermarket chains or healthcare collectives, leading to reduced reactivity by provider monopolies such as large pharmaceutical companies with consequent societal detriment. By paying (a lot) for treatment today, a patient gets the opportunity to encourage innovation and competition by freeing the market (a little) for others who follow with cost and availability benefits for them. The opportunity to improve the world is a common aspiration: permitting its expression meets the criteria of beneficence and respect for autonomy while denying paternalistic expression of the prescriber’s view of distributive justice. This further principle might be termed “Market Altruism” and is commonly seen expressed in its negative form by those, typically elderly, who express their autonomy by refusing expensive state subsidised drug for conditions that they see as being of insufficient beneficence according to their perceptions of distributive justice. Competing interests: I have been a Conservative Parliamentary Candidate |
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Rosetta Manaszewicz, Steering Committee Member, Breast Cancer Action Group (Vic.) PO.BOX 381 Fairfield, Vic. Australia
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Sir, I believe that Dr. Leopold has entirely missed the point of the Jefford et.al paper. The issue is not what a 'reasonable doctor' would advise but rather, what information he would provide his patient in order to facilitate truly informed decision making. This, I would argue, is the hallmark of ethical practice - medical decision making on the basis of full, comprehensible and comprehensive information. Anything less is to deny patient autonomy and hence, 'unethical'. Competing interests: None declared |
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Michael P. Brown, Senior Consultant in Medical Oncology Royal Adelaide Hospital Cancer Centre, Adelaide, SA 5000, Australia, Ian N. Olver
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Michael Jefford’s article “Medical paternalism and expensive unsubsidised drugs” reminds us that necessity is the mother of invention. As a society and as clinical oncologists, we must begin to find new cost effective ways to provide equitable access to the innovative, effective and expensive drugs that are making cancer a chronic rather than rapidly lethal disease. Drugs such as trastuzumab and gefitinib are safer ‘targeted therapies’ that only attract government subsidies after the pathologist identifies the target present in a minor subset of patients. For example, gefitinib may produce ‘Lazarus’ responses among patients with epidermal growth factor receptor (EGFR) mutation-positive non-small cell lung cancer (NSCLC) (1). Significantly, median survival was not reached in two NSCLC studies (1, 2). Further, optimal use of temozolomide for treatment of glioblastoma multiforme depends on knowing the DNA repair enzyme status of the tumour (3). Deletion of the methylthioadenosine phosphorylase (MTAP) gene in most pleural mesotheliomas renders these tumours susceptible to treatment with pemetrexed (4). Preclinical examples include increased sensitivities of B-type Raf kinase (BRAF)-mutated melanomas cells to mitogen-activated protein kinase kinase (MEK) inhibitors (5), breast cancer 1/2(BRCA1/2)-deficient tumours to poly(ADP- ribose) polymerase (PARP) inhibitors (6) and phosphatase and tensin homologue (PTEN)-deficient tumour cells to mammalian target of rapamycin (mTOR) inhibitors (7). Maximising benefit should be the aim of spending anyone’s money on expensive drugs. Thus, as we enter the era of personalised medicine, use of expensive targeted therapies should be limited to pathologically proven indications because truly effective drugs are best applied to those individuals who would most benefit. Although funding of the pathology tests required for use of the targeted therapies remains a challenge. It follows that clinical oncologists should be trained properly to use targeted therapies. Then a new generation of clinical oncologists would be empowered to participate in the iterative cycles of research between bench and bedside that are necessary for optimal use of biotherapies and their integration into multimodality cancer treatment programs. We propose that molecular pathology (tumour pathology and cancer genetics) be made available as a training option in the postgraduate education of clinical oncologists. Clinical oncologists and pathologists would jointly administer and mutually accredit the training module, which may also contribute toward the award of a higher degree. References: 1. Taron M et al. Clin Cancer Res 11, 5878, 2005. 2. Lee DH et al. Clin Cancer Res 11, 3032, 2005. 3. Hegi ME et al. N Engl J Med 352, 997, 2005. 4. Adjei AA. Clin Lung Cancer 5 Suppl.2, S51, 2004. 5. Solit DB et al. Nature 439, 358, 2006. 6. Farmer H et al. Nature 434, 917, 2005. 7. Neshat MS et al. Proc Natl Acad Sci USA 98, 10314, 2001. Competing interests: None declared |
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