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Speaker: Thomas Stossel , American Cancer Society Professor of Medicine, Harvard Medical School
Dr. Stossel's lecture can be viewed online. Also, an adaptation of Stossel's lecture was published in the May/June 2010 issue of Boston Review.
On March 4, 2010 Dr. Tom Stossel, from Brigham & Women's Hospital and Harvard Medical School, spoke on "Money in Health care - Sin or Salvation?" His talk warned against approaching private money in medicine "religiously," as he put it, as either sin or salvation. Dr. Stossel defended what he sees as a more nuanced approach.
He argued that the main drivers of recent health improvements in America are health products which, in recent decades, were increasingly generated with industry money: federal funding remained constant. This is no coincidence, since industry funded research tends to be closer to the "bed" end of the bench-to-bedside continuum: it culminates in the production of drugs and devices that help patients. Regulation of the private medical industry thus risks palpable, and potentially enormous, health benefits. It may lead to insufficient risk-taking, to meager investment, and to limited budgets for education.
Dr. Stossel contrasted this palpable health risk with worries about conflicts of interest in medicine. In his view, such worries tend to be speculative and non-evidence based. They often focus on abstract fears about loss of public trust in the profession, without data to support that fear. In this vein, Dr. Stossel critically examined an oft-cited 2000 review by Ashley Wazana and colleagues at the Journal of the American Medical Association. He also noted that despite widespread speculation about corruption, only a handful of US court cases have surrounded pharmaceutical company corruption, and settlement agreements usually reflected the enormous cost for companies from potential disbarment, not the merit of the claimants' complaints. In response to the claim that industry's involvement in science generates bias, Dr. Stossel noted the inevitability of bias in all human affairs; the point of scientific inquiry is to check one's biases. In fact, he suggested, protest about corruption in medicine typically comes from academics who built careers on such protest, a potential form of corruption and abuse of power in its own right.
Dr. Stossel conceded that conflicts of interest can be problematic, and that practices like kickbacks and plagiarism are clearly wrong. However, he insisted, the issue should be assessed on a case by case basis, and based on evidence, rather than through the wholesale elimination or minimization of conflicts of interest. In fact, America's founding fathers understood that conflicts and factions of a different sort, while bearing certain risks, can be managed through checks and balances. Eliminating conflicts would have foregone enormous benefits.
Dr. Stossel warned about confusing what he calls merit and value. The former is a form of lofty abstract virtue, or sense of calling, which practitioners are alleged to have held before big money entered medicine. It is essentially a Lutheran idea, and a remainder from an era of pretty bad, non-value generating medicine. But value, that is, clinical outcomes like prolonging life and improving life quality, is what we should be after.
Dr. Stossel concluded:
- Product money in health care is best approached in a nuanced practical spirit, not as a matter of abstract ethics.
- The medical value that money generates matters far more than its provenance.
- Regulation based on the assumption that money corrupts healthcare often manifests abuse of power.
Nir Eyal, Faculty Fellow in Ethics 2009-10