When partisans want to terrify Americans about their access to health care, they use a code term: rationed care. It turns out that doctors and hospitals nationwide already have made that frightening prospect real: They tell the New York Times that drug shortages have forced them to make tough choices about limiting which patients get optimal treatment for serious conditions, including bladder and ovarian cancer, leukemia, Hodgkin’s lymphoma, myeloma, hemorrhages during heart surgery, and kidney disease.
Most practitioners and institutions don’t inform patients about drug shortages or curtailed care. Some hospitals and doctors say the whole situation puts them in a major ethical quandary.
It’s curious, though: the story doesn’t address as much as it might, in my view, a more fundamental issue: Big Pharma greed.
Let’s start with the terrible basics — how sweeping shortages of important drugs have become and the consequences. As the Times says:
In recent years, shortages of all sorts of drugs — anesthetics, painkillers, antibiotics, cancer treatments — have become the new normal in American medicine. The American Society of Health-System Pharmacists currently lists inadequate supplies of more than 150 drugs and therapeutics, for reasons ranging from manufacturing problems to federal safety crackdowns to drug makers abandoning low-profit products. But while such shortages have periodically drawn attention, the rationing that results from them has been largely hidden from patients and the public.
Individual physicians and institutions on their own not only must figure how to work around missing medications. They also must determine who gets the short supply. It is done, “ad hoc,” and more often than not without patients knowing.
The treatment questions swiftly get confounding: If a medication is rationed, do ailing kids get it before sick grownups do? Does the sickest pediatric cancer patient get the drug in short supply? Or does it go to the child with the best prospects? If dosages are determined by size and weight, do we give limited, needed medications to several skinny patients or one who is sick and obese? Do we let a patient just bleed a little more during surgery and take that risk when drugs aren’t available?
The Times points out that, even with elective procedures, patients aren’t told and aren’t consulted about drug shortages that may affect them. Although many institutions have standing, well-organized, and well-run ethics committees, hospitals often don’t engage them in the considerations about rationed drugs; individual physicians all too often are left on their own, or within specialty practice groups, to struggle with profound questions about care. The Times describes well and painfully the human dimensions of drug shortages.
This issue is hardly new. It has blown up recently, especially because, as I have written, Big Pharma profiteers have sought to press the boundaries of greed and decency. They are taking old, familiar drugs, some of them vital to relatively small groups of patients, and jacking up prices to gain new revenues.
Big Pharma also is having its cake and eating it by exploiting patent protections. Yes, it costs a lot to develop effective meds. But companies get to keep their formulations secret for decades so they reap long profits. Even after drugs fade from their initial burst of profitability, they continue to generate revenues — it’s a question of how much. Companies drop long-standing and still-effective drugs to make more money on newer meds. When certain pharmaceuticals can be produced by others, especially through compounding pharmacies, costs here also are a huge driver. Some academic medical centers are large enough so they can run their own pricey, compounding pharmacies to expand their medication options. But we’ve also seen how greed can kill in corner-cutting compounding companies.
Big Pharma has inflicted the drug shortage woes worldwide, though Canada, for example, has taken some actions that are worth U.S. consideration (including a government-sponsored web site that lists drugs in short supply and lets the public know what’s being done). Numerous health policy researchers are working on the issue. Congress also has given the FDA new powers, since 2011 or so, to try to address supply issues. Clearly, even more needs to be done on this issue with patients’ needs, not those of Big Pharma, at the fore.