June 25, 2016
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June 24, 2016
Ezekiel J. (Zeke) Emanuel,
MD, PhD, is chair of the Department of Medical Ethics and Health Policy at the
University of Pennsylvania. On May 30, 2016, the Washington Post published an
opinion piece by Dr. Emanuel titled “Want to Win $2 Billion? Create the Next
In the article,
Dr. Emanuel makes two key points: (1) the low cost of antibiotics may be one of
the principal factors that have led to doctors over-prescribing these drugs;
(2) the low cost of antibiotics with the resulting low rate of return on
investment for pharmaceutical companies dis-incentivizes drug manufacturers
from allocating more resources for the research and development of new
antibiotics to combat evolving “superbugs” (bacteria resistant to current
antibiotics). He offers ideas to help solve the problem including: (1)
mandating that all hospitals create antibiotic stewardship programs to monitor
antibiotic use within institutions; (2) require that all antibiotic
prescriptions written be reviewed to assure that the prescribing is warranted
according to national guidelines; (3) increasing the charges for antibiotics;
and (4) creating a $2 billion prize with additional taxes or surcharges to be
awarded to individuals or entities that develop new antibiotics to counter
identified microbial threats.
One should be very
careful in challenging any suggestions Dr. Emanuel might make – after all he is
an internationally recognized health policy and medical ethics expert – but in
this case I think he is mistaken about issues and that his ideas may have
unintended negative consequences that will make matter worse.
Decades years ago,
antibiotics were far more expensive than they are today. Loss of patent
protection and generic substitutes have substantially lowered antibiotic costs.
But the cost of the antibiotics a few years back had little to do with the
development of resistant organisms. One might argue that antibiotics perhaps are
far more readily available than is good for man. (One example is farmers using
antibiotics to improve their beef cattle and dairy herds.) Antibiotic
resistance is as evitable as natural selection; resistance evolves from
appropriate and inappropriate use.
Without question, antibiotics
are too freely used and are unnecessarily available. The Centers for Disease
Control and Prevention has estimated that over half of the outpatient
antibiotic prescriptions written are medically unnecessary. Some might suggest
that they be available without prescription. If it were safer to use
antibiotics without proper provider oversight, certainly they would be marketed
as over-the-counter drugs in the US. But with evolving resistance, it is also
apparent that antibiotics should be accessible only with better foresight and
But even if we in
the United States were to dramatically curtail antibiotic use by prescribing
drugs more appropriately, one should still ask “What about the rest of the
world?” The US has 4% of the world’s population. In the US (and more developed
countries), we are very concerned about the availability of antibiotics and
appropriate use; but most of the world is not. Antibiotics are readily
available in Central and South America and Asia and Africa without a
prescription. Clearly resistant organisms will continue to evolve in the world
whether we decrease the rate of resistance in the US or not. Moreover, the more
recent worldwide epidemic health scares have been from viruses – Ebola, Zika,
– for which antibiotics are of no help.
The very best
strategy in combating resistant organisms remains prescribing antibiotics
appropriately. Successful ideas to help prescribe antibiotics more
appropriately have been proposed.
Somehow, we need to get providers to practice evidence-based medicine. Of
course, we should be doing this in every aspect of providing care, not just in prescribing
antibiotics. Our primary ethical obligation as providers is to practice
competently. Radical ideas – like increasing the cost of antibiotics, mandating
that all hospitals have antibiotic stewardship programs, asking more
knowledgeable peers to review every single antibiotic prescription, and taxing
Medicare hospitals to create prize money to award successful antibiotic
developers – may work; but the formula seems too extreme. If we need peers
watching everything that other providers do, is this really the solution that
will assure best practice over the long haul?
June 24, 2016
Patients often rely on physicians for information about their treatment alternatives. Unfortunately, that information is not always objective. Consider a man with early stage prostate cancer interested in surgical removal of his tumor, but uncertain whether it is better for … Continue reading →
The post Doctors Can’t Be Trusted to Tell Patients Whether They Should Receive Robotic Surgery appeared first on PeterUbel.com.
June 24, 2016
This painting (National Gallery of Scotland) from the 1400s depicts "Christ Disputing with the Doctors." The conflict between religion and medicine is a common theme in many recent brain death and futility conflicts.
June 23, 2016
I was surprised to see this Gerard David painting at the National Gallery of Scotland. The 1510 painting from the Netherlands depicts St. Nicholas dressed as a bishop reviving three boys who had been murdered and salted down for meat during a fam...
June 22, 2016
Last week I had the opportunity to attend the annual summer conference of the Center for Bioethics and Human Dignity. This year’s conference was titled Transformations in Care, and it was focused on how medical care is changing and the ethical challenges that go along with those changes. As usual, the conference was excellent with thought-provoking speakers and interesting workshops and paper presentations. One of... // Read More »
June 22, 2016
The results of this study in Clinical Transplantation should come as no surprise. Mainstream media provides poor education to the public on brain death.
The authors argue that because public understanding of brain death impacts organ and t...
June 21, 2016
There are at least five ongoing US court cases involving brain death. They can be grouped into three categories:
Is Family Consent Required for the Apnea Test?
1. Alex Pierce (San Bernardino County, California Superior Court, though thi...
June 21, 2016
Hearing the Call: A Feature on How Physicians and Medical Educators Came to Understand their Vocation By Deb Roman The children tried to cope, but at times, the best they could do was to go into a room and scream, sometimes for more than an hour, emerging exhausted and distant. They struggled to ﬁnd comfort […]
June 21, 2016
A recent report underscores the paucity of mental health research relevant to LGBT patients. According to Celia B. Fisher, Ph.D., Director of the Fordham University Center for Ethics Education this unfortunate situation is not unique to research studies. “In our … Continue reading →