A few weeks ago I gave a talk about the ethics of high cost pharmaceuticals at a Connecticut Health Council event. After I accepted the invitation I was initially at a loss about what to say. Simply excoriating Turing Pharmaceuticals for raising the price of Daraprim by 5,000% would be too easy. But when I asked myself what allowed Turing's actions to be grossly unethical but completely legal, I saw that three competing ethical frameworks - "good vs good" conflicts - help explain why we've been so impotent in relation to drug prices.
- Free market theology vs ethics of care. A teaching from Milton Friedman's Capitalism and Freedom has achieved the status of unquestionable religious truth for many: "There is one and only one social responsibility of business - to use its resources and engage in activities designed to increase its profits so long as it...engages in open and free competition, without deception or fraud." But many of those who are deeply involved in health care, including many in the pharmaceutical industry, see their work as a calling, in the spirit of Hippocrates, who articulated the ethics of care 2500 years ago. Both frameworks embody ethically admirable values. But in many sectors of the US health system, with the current pharmaceutical industry as a prime example, the theological commitment to free markets is overly dominant.
- Life is priceless vs opportunity costs matter. More than 30 years ago, in his deservedly admired evocation of the ethics of care, Norman Levinsky invited physicians to believe that the sacredness of their calling meant that the opportunity costs of our interventions should not be considered: "physicians are required to do everything that they believe may benefit each patient without regard to costs or other societal considerations. In caring for an individual patient, the doctor must act solely as that patient's advocate, against the apparent interests of society as a whole, if necessary...When practicing medicine, doctors cannot serve two masters...The doctor's master must be the patient."
These are stirring words, and in my teaching I've found that most physicians embrace them with pride. But looked at closely, it's clear that Levinsky's passionate embrace of the ethics of care led him into the error of ignoring opportunity costs. When physicians indicated solidarity with Levinsky's position I sometimes responded as follows: "Doctor - congratulations on your altruism. If your patient needs a heart transplant and you are the only match, you're prepared to donate your own heart!"
Until recently, the "life is priceless" ethic led us physicians to ignore the impact our interventions imposed on individuals and wider society. Nurses, social workers, and other health professionals have been more attuned to the way the over-costly health system harms population health by undermining income and other social determinants of health. Only now, with drug prices going through the roof, are we physicians beginning to see the limitations in Levinsky's noble and inspiring rhetoric.
- Government is the problem vs government is [part of] the solution. My generation (I was born in 1939) was conceived in the New Deal era, came into adulthood during Lyndon Johnson's Great Society movement, and have watched the pendulum swing from inflated confidence in government action to the nihilism of the Tea Party and the Freedom Caucus.
The crucial point is that the three conflicting frameworks represent "good vs good" conflicts, not "good vs evil." As such they call for a political culture that is prepared to follow Winston Churchill's advice:
Nationally, we lack the courage to listen. This has led to a failure to balance the three competing ethical frameworks. Runaway pharmaceutical prices reflect our theological commitment to free markets, the reluctance of the medical community to consider the opportunity costs imposed by health care expenditures, and the national distrust of government action. Mature organizations speak and listen. At present, our political culture cannot do both. We see one result of the national skill deficit in our inability to rein in pharmaceutical pricing.