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I am very pleased to see the response by J S Taylor to my critique of the “organs debate”. He makes some notable and important points, but also some errors to which attention should be drawn.
Taylor erroneously attributes to me concern that the organ debate excessively focuses on saving the lives of a few people. My concern was about the narrow framework within which the debate is embedded and that it focuses on the lives of a few privileged people—those who can pay—while largely neglecting the lives of those who cannot. The fact that some attention has been paid to such issues in some journals does not negate the importance of my claim. Moreover, it is not that the question of millions of premature deaths has not been addressed as fully as I would like, as Taylor claims, but rather that it has not been addressed as fully as required by the magnitude of the problem.1 There is more than a subtle distinction between what I wrote and Taylor’s interpretation of this. The organs debate may indeed justifiably be seen as separate, but his fear that taking on the broader debate may diminish “our understanding of issues in the organs debate” is unconvincing.
Taylor claims that my heightened concern for the “lives of millions” leads me to overlook that these millions are “simply” (my italics) an “aggregate of individuals”. As a physician who has personally delivered health care to thousands of individuals over almost four decades, and who has been privileged to receive good care, I am well aware of the importance of caring for individuals. I am, however, also deeply aware that population health is not simply an extension of the health of individuals.2 Taylor may be correct that this could be the case if everyone had reasonable access to basic health care, but he is certainly not correct when access to health care is a privilege to which only some have access. The falsity of his claim is plainly evident in the USA. There, despite spending 50% of annual global health expenditure on 5% of the world’s population (more than $5000 per person on health annually—about twice that spent in any other nation in the world), millions of Americans lack access to health care.3 Moreover, the level of population health achieved in the USA is well below that achieved in many other countries.4 The incredulity of his claim is even more evident at the level of global health—where the wide and widening disparities in access to health care arguably constitute one of the major challenges to human life and security everywhere.5
It is undisputed that the purpose of medical practice and research is becoming increasingly influenced by market forces and market language. It is notable—for example, that of about $70 billion spent annually on medical research 90% is devoted to those diseases that account for 10% of the global burden of disease. The pharmaceutical industry has a major influence on medical practice and research, which is why of 1393 new drugs marketed from 1975 to 1999 only 16 were for tropical diseases or tuberculosis.6 It seems that the purpose of medicine and medical research has been hijacked to serve the health and economic interests and the scientific curiosity of the most privileged!7
The essence of my concern is that bioethics is in danger of being coopted into this agenda as exemplified by, although not limited to, the organs debate, with its excessive focus on the individual choices of those who can pay. The disagreements between Taylor and me are less important than the recent pleasing upsurge in interest in public health and public health ethics, which offers a broader moral perspective within which bioethics debates could contribute a more visionary approach to health and to saving lives.8,9,10