Category Archives: Ethics

Kaiser Health News notes:

Last year, about 80,000 emergency-room patients at hospitals owned by HCA, the nation’s largest for-profit hospital chain, left without treatment after being told they would have to first pay $150 because they did not have a true emergency.

Sound’s reasonable? 

Physicians worry that sick people will forgo treatment. There is no data on how many who leave the ER without treatment follow up with visits to doctors’ offices or clinics.

“This is a real problem,” said Dr. David Seaberg, president of the American College of Emergency Physicians, who estimated that 2 to 7 percent of patients screened in ERs and found not to have serious problems are admitted to hospitals within 24 hours. (Medicynical emphasis)

“After you’ve done the medical screening, it makes little sense to not go ahead and write a patient a prescription,” said Dr. Michael Zappa, a Boca Raton, Fla., hospital consultant and former president of the Florida College of Emergency Physicians.

Medicynical Note:  ER care is not a solution to the severe health care access problem for the indigent and those lacking insurance.  ER care is the most expensive and most inefficient care in the world.  However, at present, most locations in our country do not have alternative more efficient facilities available.   And when people with medical problems, seemingly “non emergent” are turned away we create an incubator for the development of serious problems.  This is hardly an enlightened or reasonable health care system.

What distinguishes the U.S. health care from that provided in other industrialized countries is that ours is not provided in a systematic organized fashion.  As we’ve noted it is a non-system of care, that is slowly but surely bankrupting us individually and collectively.

Our conservative friends may be in denial but health care reform approaches this ethical medical issue by assuring coverage to almost all of us.

Patients with Multiple sclerosis face a number of potential complications from the drug Tysabri including progressive multifocal leukoencephalopathy (PML) a potentially fatal brain problem.  Patients trying to decide whether or not take this drug apparently are deviled by the question of their doctor’s conflict of interest.  As this patient found out her physician who presumably had her best interest at heart, was also taking funding from the manufacturer of the very expensive medication that he recommended, Tysabri.

Where I live, a state law mandates that payments any doctor receives from a drug company be reported to the Minnesota Board of Pharmacy, which enters it int a public database.

When I looked up my neurologist, what I found was damning. He had received more than $300,000 from drug companies between 2006 and 2008. (The 2009 data weren’t yet available.) Major contributors to this sum were Biogen, the manufacturer of Tysabri and the sponsor of the clinical trial my neurologist suggested to me early on, and Teva Pharmaceuticals, the manufacturer of Copaxone. In addition to many payments for acting as a speaker from these companies, my neurologist also had been compensated for “promotional/marketing consulting services.”

Medicynical Note:  $100,000 here, $100,000 there, soon we’ll be talking real money.  It’s difficult for me to believe that this money didn’t in some way influence the doctor to recommend the medication and influence that patient to participate in a trial of the medication.  Often in such trials, the more patients recruited the higher the payments.

A whistleblower at Madigan Army Medical Center believes he is a victim of retaliation for his efforts. For a time, two cardiologists at Madigan received payments from a medical device manufacturer (Boston Scientific). The cardiology department at the time insisted only on using devices from that manufacturer. The cardiologists, who were found in conflict with the Army’s policy, maintain their patient care judgment was not prejudiced.

Subsequently

Eisenhauer (Medicynical note: the whistleblower) says his own reputation and career came under attack from his supervisors at Madigan, located at Joint Base Lewis-McChord, south of Tacoma. “Not only did they do nothing to correct the situation, they participated in a scheme to run me off,” said Eisenhauer, who was awarded a Bronze Star service medal for his duty in Iraq in 2009. “It was easier to discredit me than address the criminal activity.”

It should be noted that:

investigation resulted in a guilty plea by Maj. Jason Davis, then Madigan’s chief of cardiology, who admitted to taking more than $4,800 in illegal payments from Boston Scientific.

The long-standing practice of drug companies and medical-equipment manufacturers offering doctors free trips, speaking honorariums and other payments is controversial. Critics say the money may often represent kickbacks for favoring a company’s drugs or devices.

Still, in civilian practices such payments are generally considered legal. In the military, however, doctors are prohibited from taking such payments. (Medicynical Note: Not very reassuring)

Read the article for details on the hassles Eisenhauer faced and the reasons he left the military.

Medicynical Note: The problem was deeply rooted at Madigan, and according to Eisenhauer 1.2 million dollars in sole-source acquisitions, presumably in cardiology alone, were pushed through. Imagine the cost if similar practices are extant at other military facilities–as they undoubtedly are.

Consider also the cost implications of such bribery (for lack of a better description) on the more massive civilian health care sector.

Pfizer is in a long running dispute with the Nigerian government and parents regarding children who died during a meningitis epidemic in 1996.

For background from a 2009 article:

Kano’s infectious diseases hospital, a small collection of concrete buildings inside a sandy compound, was overwhelmed, even after teams from Médecins sans Frontières arrived. They were dealing with not one but three epidemics – measles and cholera had broken out as well. Children were being seen and treated in overcrowded halls and corridors. It was chaos.

And then a chartered DC-9 flew in from the US. On board were doctors from Pfizer, the world’s biggest pharmaceutical company, and better medical equipment than the African town had ever seen. They had come to conduct a trial of an oral antibiotic called Trovan, which they wanted to test in children with meningitis against the “gold-standard” treatment of the western world, ceftriaxone. They took over part of the hospital and dosed 200 children, half with Trovan and half with ceftriaxone. And then they left, leaving behind some surplus drugs and equipment for the hospital.

Using a local facility for the purposes of testing a new unproven drug already raises ethical questions. Arriving and in cold-blooded fashion selecting just 200 patients for participation in the trial and then leaving with the epidemic still raging is at least insensitive and at worst, a damning example of the drug company’s opportunistic quest for profits.

Even worse, the Pfizer never intended the drug for use in Africa, the testing against meningitis there was simply a quick and very dirty way to accrue patients.

But the drug is not to be found in African pharmacies. It was trialed on African children, but never intended for Africa. Pfizer aimed to sell it in the USA and Europe – and yet its licence was withdrawn in Europe because of concern over liver toxicity. It is not licensed anywhere for children.

Pfizer maintained that what they did was “ethical” and that they provided the drug free of charge during an epidemic.

A suit is has been in progress in Nigeria and in the process of being settled.

The world’s biggest research-based pharmaceutical company announced on Thursday that it had made payments of $175,000 (£108,000) to each family. More such compensation settlements are expected to follow.

Also:

Legal action filed against the company alleged that some received a dose lower than recommended, leaving many children with brain damage, paralysis or slurred speech.

US-based Pfizer had argued that meningitis and not its antibiotic had led to the deaths of 11 children and harm to dozens of others. But in 2009 it reached a tentative out-of-court settlement with the Kano state government worth $75m.

And:

The cable reported a meeting between Pfizer’s country manager, Enrico Liggeri, and US officials at the Abuja embassy on 9 April 2009. It stated: “According to Liggeri, Pfizer had hired investigators to uncover corruption links to federal attorney general Michael Aondoakaa to expose him and put pressure on him to drop the federal cases.”He said Pfizer’s investigators were passing this information to local media.”

Pfizer has subsequently denied the contents of the cable.

Medicynical Note: Pfizer’s insensitivity is quite remarkable. What’s more cynical than delaying resolving this mess for 15 years? What’s more cynical than testing a drug in a place where you never intend to market it–because it will be too expensive? What’s more cynical and opportunistic than flying in a research team in the middle of an epidemic to do drug trials……and then leaving?

It’s enough to give us all, my profession and the formerly “ethical” drug manufacturing companies, a bad name.