Academic journal article
By Brezis, Mayer; Belmaker, R. H.
The Israel Journal of Psychiatry and Related Sciences , Vol. 45, No. 2
Mayer Brezis, MD, MPH
Center for Clinical Quality & Safety, Hadassah Medical Center & School of Public Health, The Hebrew University of Jerusalem, Israel
Abstract: A landmark paper on Game Theory showed that individual maximization of profit necessarily endangers the public good, and since the problem has no technical solution, "it requires a fundamental extension in morality" (1). We propose here that public health, as a public good, now emerges as a grave example of this problem. Recent events and reports increasingly suggest misalignment between the interests of the pharmaceutical industry and those of public health. Johnson & Johnson illegally and effectively promoted Propulsid off-label for children despite internal company documents raising safety concerns. Death in drug trial has been described as a "trade secret." On Vioxx, Topol wrote: "Sadly, it is clear that Merck's commercial interest exceeded its concern about the drug's toxicity" (2). More and more concerns are raised by scholars and major journal editors about the type and the quality of published evidence, often biased towards efficacy of new products. The industry, funding over 80% of trials, sets up a research agenda guided more by marketing than by clinical considerations. Smart statistical and epidemiological tactics help obtain the desired results. Budget for marketing is by far greater than for research. Massive advertising to physicians and to the public gets increasingly sophisticated: ghost writing, professional guidelines, targeting of consumer groups and manipulating media for disease mongering. Pervasive lobbying and political ties limit the independence of regulatory bodies. Obligation to shareholders overriding public health considerations is not unique to the pharmaceutical industry. The chemical, tobacco and food industries share similar tactics: proclaiming doubts about safety issues, buying researchers, infiltrating universities, boards, media and legislative agencies. By contrast, powerful and cheap health promoting activities, poorly supported by industry because they are too cheap and not patented, are markedly underutilized: technologies for changing behavior (e.g., cardiac rehabilitation), palliative care and use of old, effective and safe drugs - all could benefit from industry's tools of marketing and quality. As those most affected are the sick, the poor and the least educated, free market successes appear to pose unsolvable challenges to social justice in public health.
Social Justice in Health Care
In recent consensus papers on modem physicians' ethics, social justice appears as a fundamental novel principle, not present in the classical Hippocratic Oath. The Ethics Manual, published by the American College of Physicians, declares (3): "Physicians (...) should promote justice in the health care system and should base allocations on medical need, efficacy, cost-effectiveness and proper distribution of benefits and burdens in society."
While the pharmaceutical industry has significantly contributed to therapeutic advances, in recent years the exponential rising cost for medicine (4) is not necessarily translated into far better health care or into increase in longevity. Investing this money in health promotion, clinical quality and safety, or palliative care could in fact be more cost-effective.
Given the profit motive that underlies industry's activities, a general question that emerges is: How solvable is the conflict of interests between private enterprise and public health? Adam Smith, who presciently viewed the modern free-market, claimed: "by pursuing his own interest he frequently promotes that of the society..." (5). More recently, however, a landmark paper on Game Theory described "the Tragedy of the Commons" and showed that individual maximization of profit necessarily endangers the public good, and since the problem has no technical solution, "it requires a fundamental extension in morality" (1). …