costs in an elastic economic environment, we would just shrug
our shoulders and say that is the price of saving lives. But we don’t
have an elastic medical economy, and we would be treating large
numbers of people who will not receive any benefit from treatment.
Unlike HIV where failure to treat will rapidly lead to high rates
of morbidity and mortality; HCV is a slow growing virus. Eighty
percent of infected individuals never have symptoms. Of those
twenty percent who do develop liver disease three-fourths (i.e.15%
of the total infected population) will develop significant liver disease
but not die from the virus. It is an estimated 3 to 5% of all infected
individuals who will die from their disease. But even if we look at
the number needed to treat to prevent any significant disease, it
would take half a million dollars of treatment to prevent one person
from developing significant liver pathology; and nearly two million
dollars per life potentially saved.
Doctors are usually not comfortable talking like this, i.e. putting
a price tag on potentially life-saving treatment. But if physicians
look to see where the dollars might have to come from to provide
the funding to “knock out Hep C,” we would be looking at significant cutbacks to essential services such as law enforcement, our
military, and public education. Alternatively, Hepatitis C funding
could come from cannibalizing dollars directed toward treatment
of other diseases.
Such a scenario might pit breast cancer against Hepatitis C. It
could be that funding for diabetes, Crohn’s disease, hypertension,
and newborn care could all suffer if society values eradication of
Hepatitis C more than these other conditions. And it is not just
“society” in a general sense making these judgments. Living now
in Philadelphia, I have had discussions with gastroenterologists
and infectious disease specialists who are advocating so hard for
their patients to receive treatment (even in the face of continued IV
illicit drug use), that some have literally told me that it is not their
concern where the money comes from, they just want to see their
patients treated. In my view, this breaches the AMA standards for
the medical ethical principles of Justice.
The discussions on the distribution of financial resources are
not commonly couched in ethical terms. The issues around the
new treatments for a chronic disease that affects more than 1%
of the US population would evoke both the ethical principles of
the provision of competent, compassionate care for individual
patients, the use of advanced scientific knowledge in the care of
patients, and regarding the care of individuals as paramount. But
with the cost impact of these drugs causing potential disruption of
resources for society and/or for other diseases, the treatment runs
afoul of the ethical principles improvement of community health
and of supporting access to medical care. The Washington Post
article, “New hepatitis C drugs’ price prompts an ethical debate:
Who deserves to get them” (May 2, 2014) quotes Dr. Gary Davis,
the co-chairman of the American Association for the Study of Liver
Disease—Infectious Diseases Society of America (AASLD-IDSA).
He is reported to have said, “We just put down the best regimen for
the individual. We recognize cost issues are really important, but
we are clinicians, not the people who should be addressing that.” If
expert clinicians make recommendations based upon science and
what is possible without considering the ramifications of resource
allocation, then how can they be surprised if they have little to say
about the final decisions? In order to assume true leadership in the
health care arena, physicians must balance the ethical decisions on
population health with those for individual patient care. To do less
physicians are speaking with only a portion of their ethical and moral
authority. Assumption of leadership puts doctors in often difficult
decisions. But most doctors make difficult clinical decisions on a
daily basis. The profession demands that physicians become more
engaged in public policy decisions.
The ethical discussions need to be taken to a more granular
level. I have had the privilege of sitting on the National Quality
Forum’s Cardiovascular Disease Work Group, where both patients
and doctors have openly worried that resources for heart disease
will suffer as money is re-routed to treatment of Hepatitis C. The
National Quality Strategy has had reduction of heart disease as the
key element for improving the overall health of the nation. Now
the cardiologists and others concerned about heart disease are
worried. This tension between specialties has always been there,
but has been exacerbated by having such expensive cures. Will
physicians continue to enj