Protection vs. Cure: What is Right?

HEALTH WATCH

Dear readers, this week, the doctor needs your advice.

Medicine has seen so many changes in the last 50 years. New diagnostic devices and drugs have been developed, that have produced a healthier society, a higher quality of life, and longer life expectancy.

Chronic diseases have become the first causes of mortality and doctors have a huge arsenal of ‘wonder’ drugs to save lives. But, the cost of these drugs has skyrocketed, forcing doctors to put on accountants’ “green visors” when deciding who pays and how much to pay for life-saving treatment. Some doctors ask in despair: “Will lack of funds kill my patient where disease could not?”

Doctors are taught to heal, using the best available drugs and relying upon evidence-based medicine, approved by controlled studies carried out by pharmaceutical companies and government agencies.

Millions of dollars are spent over many years to bring out more effective medicines, with less adverse effects. With each successful new drug, a high price has to be paid to compensate for the millions of dollars spent on other drugs that failed.

The new, so called “biological” agents, include monoclonal antibodies, they are like “bullets” that have been genetically engineered to act specifically against certain components that cause inflammation, like in rheumatoid arthritis; or against specific tumor cells, sparing the normal host cells. They have become a revolution in therapeutics, given a life with fewer cancerous tumors, or a better quality of life to some patients with arthritis.

But these ‘magic bullets’ work no magic in your wallet. Dr Leonard Saltz, of the Memorial Sloan-Kettering Cancer Center in New York, says, “Decades ago, convention was that a drug that showed less than 20 percent single agent activity would not undergo further study. Nowdays drugs with as low as a 3 percent positive rate that improve survival by 2-6 weeks are approved”. And some of them become “state of the art” for certain conditions.

But in other cases, they prolong life free of recurrence, sometimes up to one or several years. Some of these treatments cost up to $25,000 for a single course. In countries like Panama with its small budget, doctors have a hard time balancing individual and collective medical needs.

Doctors have been taught to give the patient the best treatment, and not worry about the costs. In fact, some physicians don’t even know the cost of the drugs they prescribe.

But with the high cost of these ‘hi-tech’ medicines, not everyone can afford the best. The American Society of Clinical Oncologists (ASCO) is writing guidelines for physicians on discussing cost of treatment issues with patients.

In several countries, medical authorities have very strict rules as to which drugs are included in their recommended list (formulary), and some of them just do not include them, due to their high cost. In countries, like Panama, we also must practice cost containment, and make the best use of the little money we have. Here’s one dilemma: do you buy Human Papilloma Virus vaccines to prevent cervical cancer in many young women, or do you use it to prolong the life of a few patients with these types of cancers? Usually doctors do not want to make these decisions; they just want to treat the patient, independently of the cost, because that is the way that they were trained.

Should we spend out limited budget on those few patients that the bad luck to contract a serious disease? Probably, if it is our relative, we will pay, no matter the cost. But who should protect young (mostly poor) women from contracting cancer by receiving vaccines, and will not get the vaccines because we spent our money on drugs for patients already affected?

In English Common Law the doctrine “Patria Paterna” says that the State should protect all the sick equally, as a father would care equally for his children. This is an “individual ethic” running up against a “societal ethic”. It is a difficult question to answer, and needs to be discussed between all healthcare providers and patients.

This doctor, for one, would like to read your ideas. Dr Ulloa is a practicing internist and an advisor to the Ministry of Health.