Ethical Concerns in the Practice of Medicine

Otis W. Brawley, MD, MACP, FASCO, FACEChief Medical and Scientific Officer

American Cancer SocietyProfessor of Hematology, Medical Oncology,

Medicine and Epidemiology Emory University

Atlanta, Georgia, USA

Disclosures

• Employment:– American Cancer Society– Emory University– Turner Broadcasting (CNN)

• Consulting– National Institutes of Health– Centers for Disease Control– Department of Defense

• I do not accept money from drug and device manufacturers

3

Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine.

4

Principles of Ethics

• Beneficence• Non-maleficence• Respect for Autonomy• Justice

5

Healthcare

• An issue that must be approached ethically, logically and rationally

• We must realize the truth:– What we know.– What we do not know.– What we believe.

6

Overview

• The U.S. health economy.• Observations about our attitude

toward medicine.• Lessons from the history of medicine. • The future increased effort to prevent

chronic disease.

The Cost of Healthcare

8

U.S. Health Care Spending

In 2011, the U.S. spent

$2.7 TRILLION on Health Care

9

U.S. Health Care Spending

•How Big is a Trillion?

1 million seconds Last week

1 billion seconds Richard Nixon’s Resignation

1 trillion seconds 30,000 BCE

10

Spending in Context

2011

* Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion)

Source: Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis

17.9%

$2.7 trillion

$1.1 trillion

$1.4 trillion

Gross Domestic Product

11

Gross Domestic Product by Country, 2011Thrillion Dollars, at Official Exchange Rate

• United States 14.45• China

5.74• Japan

5.46• Germany 3.28• France

2.56• Brazil

2.09CIA Fact Book, 2012

12

Healthcare in Three Countries (2010)

• Canada

Switzerland U.S. • Infant Mortality 5.04 4.53 6.22 per 1000

live births

• White Male Life Exp 78.0 79.7 76.8 Years

• Per Capita Costs 4445 5270 8233 US Dollars

• Proportion of GDP 11.4% 11.4% 17.9%

13

Disparities in Health

• Some consume too much – (Unnecessary care given)

• Some consume too little– (Necessary care not given)

• We could decrease the waste and improve overall health!!!!

Disparities in Health

Of all the forms of inequality, injustice in health care is the most shocking and inhumane

• ML King, Jr. Presentation at: The Second National Convention of the Medical Committee for Human Rights; March 25, 1966; Chicago, IL.

15

Is there value in American healthcare?

Bringing rationality to American healthcare

Orthodox application of the science

“Rationality” not “Rationing”

The American Healthcare System

• Overconsumption of Healthcare

• The Greedy Feeding the Gluttonous

• A Subtle form of Corruption

17

Themes

• Greed

• Ignorance

• Apathy

18

Themes

People

– Who should know better, but do not

– Who do not appreciate scientific findings nor the scientific method

– Who discourage those who question

19

“A professional is someone who puts the interests of his patients above his own.”

Hal Sox, MD, MACP

20

The Doctor Culture

• Respect for tradition (Unwilling to evolve or change).

• Intolerant of those who question.

• Hubris

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

Upton Sinclair

22

The Patient Culture

The Situation.

– Demands irrational patterns of consumption

– Unreasonable expectations

– Advocacy often worsens healthcare by stressing the wrong things

The Patient Culture

For true transforming of healthcare the public needs to believe there is a crisis and it affects them.

– Personal responsibility

– Solid financial incentives (skin in the game)

The American Healthcare SystemInefficient!!!

We often do not follow the science

• We often use treatments and interventions that are lucrative to the providers but not proven effective.

• We often ignore and fail to use simple, inexpensive, and effective interventions.

Culprits in Inefficiency

• Doctors and Nurses• Patients (Consumers)• Hospital Administrators• Lawyers and Politicians• Marketers and Salesmen

(Drug and Device Companies)

Clinical Lessons Learned Late

• Chest X-ray screening for lung cancer• Urine screening for neuroblastoma• Cryotherapy for prostate cancer

Clinical Lessons Learned Late

• Lidocaine after MI • Hyper-vitaminosis (Vit E, Beta Carotene, Selenium)• Rofecoxib and Celecoxib for arthritic pain

– (Vioxx and Celebrex)• Rosiglitazone (Avandia) for diabetes

Clinical Lessons Learned Late

• Postmenopausal Hormone replacement therapy

• Halsted mastectomy

• Adjuvant bone marrow transplant for breast cancer

• Erythropoetin for anemia

Clinical Lessons Learned LateOverused Interventions

• Hysterectomy• Caesarian section• Carotid endarterectomy• Coronary Artery Bypass Grafting• Tonsillectomy• Tympanostomy

Our History of Not Respecting the Science

• The Halsted Mastectomy• Bone Marrow Transplant in Breast Cancer• Erythropoetin to stimulate blood production in

cancer patients• Mass Prostate Cancer Screening• Lung Cancer Screening

Our History of Not Respecting the Science

The Halsted Mastectomy

– Defined by Halsted in 1896– Appropriate treatment in the early 20th

century (tumors large at diagnosis)– Doctors who questioned it in the 1940’s

were disciplined– Shown obsolete in 1970’s through studies of

Fisher and Veronesi

Our History of Not Respecting the Science

Bone Marrow Transplant in Breast Cancer

• Began in 1980’s due to theory that more chemotherapy was better

• Women sued insurances to pay for it• Laws passed forcing insurances to pay for it• Clinical trials impeded• 1999, three studies show it net harmful and

200 transplant centers close in U.S.

Our History of Not Respecting the Science

Erythropoetin to stimulate blood production in cancer patients

• Approved without full testing during the AIDS epidemic as an alternative to blood transfusion

• Advertising to push the envelope in terms of FDA approval

• Suppression of studies to show it is a stimulant of cancer cell growth

Our History of Not Respecting the Science

Mass Prostate Cancer Screening

• Pushed based on early detection principles from 1991 onward

• Professional organizations warn of proven harms and unproven benefit

• Studies published 2009 to present show small benefit if any.

American Urological Association*

Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical.

Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion.

*Taken from the AUA PSA Best Practice Statement 2009 and markedly different from statements made in press conferences

Our History of Not Respecting the Science

Lung Cancer Screening

• Pushed based on early detection principles before good trials showed it saves lives

• Professional organizations warn of proven harms and suggest informed decision making

• Some hospitals push it hard and even offer at low cost without any mention of harm!

Offers Low Dose Spiral CT of the Lung to those at risk for lung cancer. ($325 cash).

“At risk for lung cancer,” according to St Joe’s, includes 40 year old non-smoking women who have lived in an urban area for more than ten years.

The business plan relies on insurance to pay for the follow-up testing of the 25% or more abnormal screens.

39

Rational vs. Irrational Medicine

• Rofecoxib (Vioxx) vs. Naproxen• Once a day vs. twice a day• $90 per month vs. $12 per

month

40

Rational vs. Irrational Medicine

Omeprazole (Prilosec)

41

Rational vs. Irrational Medicine

Omeprazole (Prilosec)

vs.

Esomeprazole (Nexium)

25 cents per day vs. six dollar per dayEight dollars per month vs. 180 dollars per month

42

True Healthcare Reform

A transformation in how we view medicine:-Less overindulgence-Less focus on treatment-Greater focus on prevention

43

True Healthcare Reform

The use of “Evidence Based Care and Prevention”

That is: The rational use of medicine

Not the rationing of medicine

Comparative Effectiveness Research

44

U.S. Smoking Prevalence by Gender 1955-2010

1950 1960 1970 1980 1990 2000 20100

10

20

30

40

50

60

MaleFemale

US Continues to Lead the World in Obesity Rates

OECD Obesity Update 2012

A Tsunami of Chronic Disease

– Diabetes– Cardiovascular Disease– Orthopedic Disease– Cancer

A Tsunami of Chronic Disease

• Will surpass tobacco as leading cause of cancer

• Think of the number of people we could save from a cancer death if we did what we know we should do

48

An Ethical Issue

• We need to focus on the prevention of disease

• We have been too treatment centered.

True Healthcare Reform(An Efficient, Value Driven Health System)

• Rational use of healthcare is necessary for the future of the U.S. economy (an issue of U.S. security)

• There is a healthcare fiscal cliff!!!

• It is possible to decrease costs and improve healthcare by using science to guide our policies 50

Otis W. Brawley, MD, MACP, FASCO, FACE

Chief Medical and Scientific Officer American Cancer Society

Professor of Hematology, Medical Oncology, Medicine and Epidemiology

Emory University

51