Tuesday, March 14, 2006

Saying No to (Expensive) Drugs?

A recent NYT article discusses the sudden price increase of a cancer drug, nitrogen mustard (marketed as Mustargen), that has recently dramatically increased in price despite the fact that has been available, unchanged, for decades.

The article deals primarily with the lack of regulation (and, indeed, rational bases beyond pure profit) governing drug pricing, in particular price increases. Included in this discussion is the following pasage:
And once a company sets a price, government agencies, private insurers and patients have little choice but to pay it. The Food & Drug Administration does not regulate prices, and Medicare is banned from considering price in deciding whether to cover treatments.

Well that's true enough. But "little choice" is not equivalent to "no choice". The always available alternative, that of choosing not to take the medicine at all rather than pay an exorbitant fee, is one that the article fails to touch upon.
We - as individuals, consumers, patients - constantly engage in health tradeoffs. We forgo sunscreen because we'd like a tan, even though it increases our risk of skin cancer. We eat french fries even after a second bypass operation because a burger just isn't a burger without them. We drive seven hours to visit relatives for the holidays, rather than fly, because airplane tickets are too expensive. All of these decisions represent common enough instances in which we are willing to trade an increased probability of harm to ourselves for some other good, e.g., an attractive tan, a pleasurable meal, or some extra money in the bank.

So why, when drug prices soar, are we so unwilling to say "enough is enough"? As drug manufacturers "increasingly point to the intrinsic value of their medicines as justification for [high] prices", perhaps its time to reexamine the categorically high intrinsic valuation of medicines.

Keep in mind that there are very few drugs on the market that are 100% efficacious. Taking an AIDS drug is not a cure, indeed it doesn't guarantee any improvement whatsoever. All it can offer is a probability of success, however "success" is defined for that particular drug-disease pairing. And, of course, it offers hope.

And, I have to imagine, it is hope that ultimately does much to explain the individual patient-consumer's tolerance for the spiraling increase of medicines and treatments. Skin cancer? That's in the future. A fatal car accident? A non-specific probability. A disease like AIDS or cutaneous lymphoma (the drug discussed in the Times article) is a present reality, often painful both physically and emotionally, and medicines like Mustargen offer the possibility of a solution.

The elephant in the room - lurking behind complaints about high drug prices, as well as debates over wrongful birth (see below), end of life care, etc. - is whether all lives are intrinsically worth preserving, regardless of the cost.

At least in the abstract there are few of us, if any, that support this position. The value of a statistical life is a common calculation for many an administrative agency, government organization, private employer...even for the individual. Ask whether the FDA is justified in preserving 12 statistical lives at a cost of $300 million and people will haggle over numbers, but they won't haggle over the basic principle that some risk of harm is inevitable in the crowded world in which we live. To attempt to prevent the loss of all lives would bring society to a grinding halt.

And yet, as soon as you put a face to the statistic - as soon as it is you or I who stand a 1 in 1,000 chance of death from a disease, rather than an unnamed, unknown individual who stands a 1 in 1,000 chance of being killed by an exploding radiator - the game changes dramatically. Expenses that would never be countenanced if undertaken for the benefit of a faceless statistical population group are accepted without second thought - after all, when it comes to your health money is no object, right?

I'm not so sure. While I can understand the emotional and personal elements involved, I also think that there is a certain amount of unthinking submission to the idea that our own health, or the health of our loved ones, is not the proper subject of a cost-benefit analysis.

To some extent I believe that attitude is correct. Money is, after all, just bits of green paper (or more accurately these days, bits representing ones and zeros in electronic bank accounts) and you can't take it with you when you go. Then again, very few of us will leave behind nothing more than our bank accounts. There will be friends, family members, and the rest of our society which we have touched in various ways.

Ultimately, like Socrates in the Apology, I find fault with the notion that death should be abhorred and life should be preserved at all costs. If you throw your grandmother in front of the bus to save your own life, will you regret that decision later? Similarly, if you bankrupt your family scooping up long-shot medications that, at best, will extend your life by a few months or years, is that a justifiable decision?

I'm not advocating any sort of strict utilitarianism here - this isn't a kill the old to feed the young proposition of any sort. All I'm suggesting, to go back to the article that started this whole discussion, is that there is always an alternative to over-priced drugs: just saying no.


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