But their case against the market goes well beyond a call for oversight. "I think that most people in the bioethics field feel that medical care is not a market good," asserts Annas. "Medical care is different from food, clothing, and shelter, all of which are market goods. It's about human mortality and human suffering, and market things are not." Consequently, Annas is a strong proponent of creating a government-financed national health care plan. "I think that that is the number one ethical issue in medicine today," he says.
Callahan concurs. He argues that we should adopt "a steady-state, equitable medicine [that] will have to limit, not expand, patient choice. It will require frank rationing. It will work to resist patient demands, particularly demands stimulated by market pressure and incentives."
Prominent bioethicists oppose the market in medicine because, they argue, when a person is sick, he or she is particularly vulnerable. Sick people can't make good decisions and can't shop around for the care they need. Money is no object: Patients just want to be cured. Thus, medical care is different from food, clothing, and shelter, all of which are market goods. But is that true? Is a sick person really more vulnerable than someone who is starving, or naked, or stuck outside in the cold?
These same sick people, who are too vulnerable to shop for medical care, are nevertheless able to give informed consent and make life-and-death decisions about their medical treatment, at least according to the original impulse behind the bioethical movement. Indeed, bioethicists advise people to craft advance directives about their medical care so that if they become incapacitated their wishes will be known. But it's apparently too much to expect them to make advance arrangements for choosing and paying for their medical care. There is no reason why most people can't shop for medical care in advance, check out doctors and medical facilities ahead of time, and purchase as much insurance as they think prudent.
"I think that the objections of people like George Annas and Daniel Callahan turn on an unsustainable egalitarianism of envy, or on an unjustifiable abhorrence for the market where the market is seen in itself as being bad," says Baylor College of Medicine bioethicist and physician Tristam Engelhardt.
The bias toward egalitarianism is pervasive among establishment bioethicists. "We should give universal access to a basic minimum of health care before going on to new, more expensive, extreme measures that will benefit only a small portion of the population," says Annas. "With 43 million uninsured, should we be trying to introduce these very expensive procedures into medicine?" Callahan also wants a health care system "in which further scientific gains are not deployed until earlier ones are fully utilized." Translation: No one should get a new treatment until everyone first has access to all of the old treatments.
"I think that Callahan is taking the view that it is more important to suffer than to have inequality," says Engelhardt. "And I think that it's a very implausible view."
Engelhardt contrasts Callahan's "egalitarianism of envy" (taking away a good from someone because others don't have it) with an "egalitarianism of altruism" (providing a good to someone who does not have it). Following the ethical nostrums of Callahan and Annas would prevent people from buying life-saving treatments that they want and can afford. But more important for those of us who can-not afford any given treatment, such bioethical barriers would drastically slow medical advances, because new treatments to which we might gain access in the future will not be developed.
As UCLA's Gregory Stock puts it, "You're getting the rich to pay for R&D. What better research subjects could you have? They are knowledgeable about the risks of the technology and can pay for it."
The issues of patient choice and the future of medical progress converged recently at a meeting of the National Bioethics Advisory Commission. A worried father named Sidney Gunst Jr. testified before the federal body in favor of allowing research on human embryonic "stem cells," which are cells derived from human embryos that have the potential to become any type of tissue. Stem cells could one day be used to cure diabetes and Alzheimer's disease, and to replace damaged tissue. Gunst's 4-year-old son has had open-heart surgery to repair a defective aortic valve, and he will need more surgery when he becomes a teenager. Gunst and many researchers think that stem cell research could lead to better transplant therapies for his son. But he is worried that the NBAC or Congress might try to stop such research.
"Every time a surgeon removes cancer from a patient, rather than letting him die, he plays God," testified Gunst. "Every time penicillin is prescribed to combat infection...or a C-section is performed to ensure a safe delivery; or an organ is transplanted rather than allowing nature to take its course--a doctor is playing God. The history of human survival is the history of man playing God."
Gunst is right to be concerned. Although sentiment on the commission generally favors stem cell research, some NBAC members have expressed reservations about it. In its recent draft report on embryonic stem cell research, the commission moves beyond philosophical deliberation to an assertion of regulatory authority. It declares that it "is charged with developing guidelines and regulations as they relate to bioethical issues arising from research on human biology and behavior (including the clinical applications of that research)." The draft adds that the commission "has an opportunity to provide a broad public policy framework for research that can prospectively anticipate [sic] scientific developments."
But even if the NBAC does give a general go-ahead for embryonic stem cell research, the commission may not approve the creation of embryos specifically to generate stem cells. Instead, the NBAC apparently will recommend that research be conducted only using embryos created first for in vitro fertilization and later donated by couples after their infertility treatments have concluded. This restriction, should it be adopted, could slow progress in stem cell research since Geron Corp. is already trying to create human embryos as sources for stem cells. The Geron researchers are doing this by inserting the genetic material from mature human cells into enucleated human eggs. If this restriction were to remain in force, it would prevent the development of the most promising stem cell treatments--the growth of new tissues using embryonic stem cells created from a specific patient's own cells. Thus, Gunst's son would be prohibited from taking one of his skin cells, putting its nucleus into an enucleated human egg, and growing new heart tissue for a perfect transplant.
Even if the commission doesn't actually ban a technology, the mere fact that it could do so has a chilling effect on biotechnological research. Scientists and companies will feel that they must submit their projects to the judgment of the NBAC before investing time and money in promising new treatments.
The whole concept of the NBAC and the ELSI program is ill-conceived. The commission may say it wants to "prospectively anticipate" problems, and ELSI was designed to be "a program that would anticipate potential problems before they actually occurred and identify possible solutions to the problems." But a mind-set that involves constantly and anxiously scanning the horizon for problems greatly increases the chances that you will eventually find them, even when they don't really exist. Agencies like the NBAC and ELSI focus on the problems a new technology might present, tending to overlook potential benefits. "Because there is a desire to get diversity on these commissions, you will always have a significant representation of those who are opposed to the technology," says Stock. "So when you reach a consensus within a committee like the NBAC it will tend to be very biased towards being very cautious."
Editor's Note: We invite comments and request that they be civil and on-topic. We do not moderate or assume any responsibility for comments, which are owned by the readers who post them. Comments do not represent the views of Reason.com or Reason Foundation. We reserve the right to delete any comment for any reason at any time.
nfl jerseys|11.15.10 @ 2:37AM|#
xhgfnch