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Three papers and a number of commentaries in this month's issue deal with the question of money in medicine. The mix of money or markets with health invariably generates strong intuitions and moral disagreement. The spirit of medicine seems to run counter to the motivations generated by financial gain. In spite of this it would be difficult in the current world to defend the claim that all traces of money should be removed from the day-to-day operation of healthcare and medical research.
The papers in this issue that deal with this question do so from three different perspectives: using tax to incentivise organ donation, paying doctors for their performance and the involvement of the pharmaceutical industry in the media.
Promoting organ donation without an opt-out system
This month's feature article addresses the increasingly difficult problem in the medicine surrounding the numbers of organs that are donated for transplant. Petersen and Lippert-Rasmussen vividly document the problems that the shortfall of donated organs causes. These problems are worse in western countries that have an opt-in system of organ donation but given the political climate in countries like the US, UK and Denmark this is unlikely to change. Petersen and Lippert-Rasmussen begin from this situation and argue for a tax-relief model for incentivising organ donation. (See page 451)
Not only does the lack of donated organs mean that people whose lives could be saved are not but for some organs, it can also mean a general deskilling of the profession. If enough transplants do not take place the opportunities for training new transplant surgeons will be limited as will the ability of practicing surgeons to maintain their technical edge. Particularly in the case of lung and heart transplants, surgeons need to be performing a certain number of procedures per year to remain at an effective level.
Faced with these difficult prospects, Petersen and Lippert-Rasmussen propose a system whereby a person receives a tax credit agreeing to become an organ donor when they die. This incentivised opt-in system is designed to encourage those who are unsure and to act as a reward for their contribution. They give five distinct arguments in favour of the tax relief idea and then consider, in some detail, 8 possible concerns about the proposal. Along the way they consider worries about commodification, exploitation, inequality and the overall costs of the system.
Muireann Quigley in her commentary questions the potential costs associated with the proposed scheme. (See page 458) She suggests that the economics are at least tighter than the authors suggest and so bringing into play questions about political will. Given the sensitive nature of incentives in this area, politicians may not warm to a tax-relief program that failed to be a clear economic winner.
James Stacey Taylor's commentary tackles the Titmuss-style objection to the tax relief problem. According to Taylor the crucial point of this objection is that “offering incentives to donate organs when such donation was previously uncompensated would eliminate the possibility that persons could ‘purely’ donate their organs in a situation where compensation was not available.” (See page 461) Taylor suggests that this objection is more worrisome than Petersen and Lippert-Rasmussen allow: it is not clear that the number of people who are encouraged by the tax credit to become donors, the ‘incentive’ donors, would exceed the number of people who would be deterred by the offer of compensation, the ‘altruistic’ donors. If this failed to occur, the rationale for the tax credit would be lost.
Petersen and Lippert-Rasmussen reply to both of these commentaries. (See page 463)
Paying clinicians to perform
In 2009 a new payment for performance scheme was introduced on a voluntary basis across France. This scheme sought to improve the quality of care through improving the adherence to guidelines and to reduce healthcare expenditure. This system is similar to the ‘Quality and Outcomes Framework’ (QOF) implemented in the UK in 2004 and has connections with initiatives in the USA, Canada, Australia, New Zealand, Israel and The Netherlands.
Importantly, these payment-for-performance schemes have not been without their ethical issues. Olivier Saint-Lary and colleagues conducted some qualitative research in an effort to understand the range of ethical tensions that arose in implementation of the French scheme. (See page 485) Most significantly the GPs in the study thought that changing the way in which they were paid led to changes in the way in which they were perceived by patients.
With increasing questions in the UK regarding competition and the new primary care commissioning structures (courtesy of the reforms of the NHS about to be brought out through the Health and Social Care Act) these questions are particularly timely.
Pharma and the media
Following the commercialisation and health theme of tax incentives for organ donation and payment for performance, Wendy Lipworth and colleagues raise questions about the relationship between the pharmaceutical industry and the media. (See page 492) More particularly they consider the ways in which pharmaceutical companies and journalists can be connected that might lead to conflict of interest, distortion and misrepresentation in the reporting of health related issues. The authors proceed to recommend a range of strategies for dealing with the relationship between industry and health journalists that parallel the steps taken within the medical community to protect healthcare professionals from similar kinds of influence.
Within the medical profession and within academic medical ethics it is very easy to find moral scepticism about the behaviour of the pharmaceutical industry. In a logical way, this paper extends moral scepticism to the relationship between industry and the ‘third estate’ as a key mediator in the presentation of information to the public and to healthcare professionals.
There is a good deal of room for response here from the pharmaceutical industry and I would hope that suggestions such as those presented by Lipworth and colleagues will elicit constructive dialogue and argument.
In the Genetics section of the journal this month, Jantina de Vries and Michael Pepper tackle an aspect of the North/South divide as it applies in medical research. In particular, they consider the role of ‘genetic sovereignty’ in thinking about research benefits and their distribution in the context of genetics research. (See page 474) Questions about genetic sovereignty arise with the exportation of tissue and other ‘genetic resources’ from Africa to the developed world for analysis. The concern associated with the concept's deployment in this context is that global health research is organised in a way that fails to adequately benefit the African communities from which the participants are drawn and does nothing to promote science in Africa conducted by African researchers.
Aside from this more political agenda, the underlying idea of ‘genetic sovereignty’ is that the genetic patterns and relationships are part of the heritage of the African peoples and so should be protected and controlled by those peoples.
De Vries and Pepper provide a close analysis of the concept of genetic sovereignty and raise important questions about its suitability to address the political concerns with which it is associated. Of particular note are their observations about the spread of ethnic groupings across Africa and the inadequacy of the boundaries of the nation state to capture the relevant genetic heritage. They argue that claims about genetic sovereignty can distract from the more fundamental and general questions associated with unfair distribution of benefits in international collaborative genomics research.
A perennial problem with controversial or sensitive issues (and indeed perhaps what adds to their controversial nature) is the tendency to polarize opinion. Groups with strong commitments or feelings on either side of a position, in the politics of argument, can be pushed into caricatures of their own genuine views.
Help is on its way courtesy of Martin Petersen's paper. (See page 496) Petersen suggests, in the context of the debate about research on human embryonic stem cells, that we introduce non-binary notions of rightness and wrongness and so allow ethical debates to be more nuanced and less polarised. The idea is that some acts can be understood as right to a slightly higher degree than others but that it does not follow from this that a rational agent should always perform the act that is right to a slightly higher degree. These claims depend on the very sensible idea that ethical reasons sometimes remain undefeated in certain contexts: even though there may be good reason to assign moral status to the human embryo and even if some may think that this reason is not as strong as that provided by the potential benefits of human embryonic stem cell research, the former need not be defeated by the latter. Once we acknowledge this, Petersen argues we are in a better position to formulate policies with which nearly everyone can live.