Huge price hikes by drug companies are immoral

Robert Klitzman
CNN.com
Originally posted September 18, 2018

Several pharmaceutical companies have been jacking up the prices of their drugs in unethical ways. Most recently, Nirmal Mulye, founder and president of Nostrum Pharmaceuticals, defended his decision to more than quadruple the price of nitrofurantoin, used to treat bladder infections, from about $500 to more than $2,300 a bottle. He said it was his "moral requirement to sell the product at the highest price."

Mulye argues that his only moral duty is to benefit his investors. As he said in defending Martin Shkreli, who in 2015 raised the price of an anti-parasite drug, daraprim, 5,000% from $13.50 to $750 per tablet, "When he raised the price of his drug he was within his rights because he had to reward his shareholders."

Mulye is wrong for many reasons. Drug companies deserve reasonable return on their investment in research and development, but some of these companies are abusing the system. The development of countless new drugs depends on taxpayer money and sacrifices that patients in studies make in good faith. Excessive price hikes harm many people, threaten public health and deplete huge amounts of taxpayer money that could be better used in other ways.

The US government pays more than 40% of all Americans' prescription costs, and this amount has been growing faster than inflation. In 2015, over 118 million Americans were on some form of government health insurance, including around 52 million on Medicare and 62 million on Medicaid. And these numbers have been increasing. Today, around 59 million Americans are on Medicare and 75 million on Medicaid.

The info is here.

How Do Medicalization and Rescue Fantasy Prevent Healthy Dying?

Peter T. Hetzler III and Lydia S. Dugdale
AMA Journal of Ethics
2018;20(8):E766-773.

Abstract

Before antibiotics, cardiopulmonary resuscitation (CPR), and life-sustaining technologies, humans had little choice about the timing and manner of their deaths. Today, the medicalization of death has enabled patients to delay death, prolonging their living and dying. New technology, the influence of the media, and medical professionals themselves have together transformed dying from a natural part of the human experience into a medical crisis from which a patient must be rescued, often through the aggressive extension of life or through its premature termination. In this paper, we examine problematic forms of rescue medicine and suggest the need to rethink medicalized dying within the context of medicine’s orientation to health and wholeness.

The info is here.

Horrific deaths, brutal treatment: Mental illness in America’s jails

Gary A. Harki
The Virginian-Pilot
Originally published August 23, 2018

Here is an excerpt:

“We are arresting people who have no idea what the laws are or the rules are because they're off their medications,” said Nashville Sheriff Daron Hall, a vice president of the National Sheriffs’ Association. “You'd never arrest someone for a heart attack, but you're comfortable arresting someone who is diagnosed mentally ill. No other country in the world is doing it this way.”

In addition to causing pain and suffering for people with mental illness, the practice is costing municipalities millions.

At least 53 percent of the deaths examined have resulted in a lawsuit. Combined, the cases have cost municipalities at least $145 million. The true cost is much higher – in many cases, lawsuits are still pending and in others the settlement amount is secret. The figures also do not take into account lawyers’ fees.

The article is here.

There are a series of articles related to mental health issues in prison.

How our lives end must no longer be a taboo subject

Kathryn Mannix
The Guardian
Originally published August 16, 2018

Here is an excerpt:

As we age and develop long-term health conditions, our chances of becoming suddenly ill rise; prospects for successful resuscitation fall; our youthful assumptions about length of life may be challenged; and our quality of life becomes increasingly more important to us than its length. The number of people over the age of 85 will double in the next 25 years, and dementia is already the biggest cause of death in this age group. What discussions do we need to have, and to repeat at sensible intervals, to ensure that our values and preferences are understood by the people who may be asked about them?

Our families need to know our answers to such questions as: how much treatment is too much or not enough? Do we see artificial hydration and nutrition as “treatment” or as basic care? Is life at any cost or quality of life more important to us? And what gives us quality of life? A 30-year-old attorney may not understand that being able to hear birdsong, or enjoy ice-cream, or follow the racing results, is more important to a family’s 85-year-old relative than being able to walk or shop. When we are approaching death, what important things should our carers know about us?

The info is here.

‘My death is not my own’: the limits of legal euthanasia

Henk Blanken
The Guardian
Originally posted August 10, 2018

Here is an excerpt:

Of the 10,000 Dutch patients with dementia who die each year, roughly half of them will have had an advance euthanasia directive. They believed a doctor would “help” them. After all, this was permitted by law, and it was their express wish. Their naive confidence is shared by four out of 10 Dutch adults, who are convinced that a doctor is bound by an advance directive. In fact, doctors are not obliged to do anything. Euthanasia may be legal, but it is not a right.

As doctors have a monopoly on merciful killing, their ethical standard, and not the law, ultimately determines whether a man like Joop can die. An advance directive is just one factor, among many, that a doctor will consider when deciding on a euthanasia case. And even though the law says it’s legal, almost no doctors are willing to perform euthanasia on patients with severe dementia, since such patients are no longer mentally capable of making a “well-considered request” to die.

This is the catch-22. If your dementia is at such an early stage that you are mentally fit enough to decide that you want to die, then it is probably “too early” to want to die. You still have good years left. And yet, by the time your dementia has deteriorated to the point at which you wished (when your mind was intact) to die, you will no longer be allowed to die, as you are not mentally fit to make that decision. It is now “too late” to die.

The info is here.

Against mourning

Brian Earp
aeon.com
Originally posted August 21, 2018

Here is an excerpt:

That is what is so different about their intuitions and ours. To put it simply, if you are not a Stoic philosopher – if you have not been training yourself, year in and year out, to calmly face life’s vagaries and inescapables – and you feel no hint of sadness when your child, or spouse, or family member dies, then there probably is something wrong with you. You probably have failed to love or cherish that person appropriately or sufficiently while they were alive, and that would be a mark against you.

You might have been cruel and uncaring, for instance, or emotionally distant, or otherwise aloof. For had you not been those things, you would certainly grieve. This, in turn, can explain why the Stoics were (and are) often thought to be so callous – as though they must have advocated such detachment from one’s kith and kin in order to pre-empt any associated suffering.

However, nothing could be further from the truth. As Epictetus instructs, one should not ‘be unfeeling like a statue’ but rather maintain one’s relations, ‘both natural and acquired, as a pious man, a son, a brother, a father, a citizen’. He also repeatedly emphasises that we are social animals, for whom parental and other forms of love come naturally. ‘Even Epicurus,’ he says, derisively, about a philosopher from a competing school, ‘knows that if once a child is born, it will no longer be in our power not to love it or care for it.’

But is it not part of loving one’s child to feel at least some grief when it suffers or dies (you might ask)? Surely feeling no grief would itself be contrary to Nature! For just as virtue cannot exist without wrongdoing, as some Stoics held, so too might the prospect of grief be in some way bound up in love, so that you cannot have one without the other.

The info is here.

Is compassion fatigue inevitable in an age of 24-hour news?

Elisa Gabbert
The Guardian
Originally posted August 2, 2018

Here is an excerpt:

Not long after compassion fatigue emerged as a concept in healthcare, a similar concept began to appear in media studies – the idea that overexposure to horrific images, from news reports in particular, could cause viewers to shut down emotionally, rejecting information instead of responding to it. In her 1999 book  Compassion Fatigue: How the Media Sell Disease, Famine, War and Death, the journalist and scholar Susan Moeller explored this idea at length. “It seems as if the media careen from one trauma to another, in a breathless tour of poverty, disease and death,” she wrote. “The troubles blur. Crises become one crisis.” The volume of bad news drives the public to “collapse into a compassion fatigue stupor”.

Susan Sontag grappled with similar questions in her short book Regarding the Pain of Others, published in 2003. By “regarding” she meant not just “with regard to”, but looking at: “Flooded with images of the sort that once used to shock and arouse indignation, we are losing our capacity to react. Compassion, stretched to its limits, is going numb. So runs the familiar diagnosis.” She implies that the idea was already tired: media overload dulls our sensitivity to suffering. Whose fault is that – ours or the media’s? And what are we supposed to do about it?

By Moeller’s account, compassion fatigue is a vicious cycle. When war and famine are constant, they become boring – we’ve seen it all before. The only way to break through your audience’s boredom is to make each disaster feel worse than the last. When it comes to world news, the events must be “more dramatic and violent” to compete with more local stories, as a 1995 study of international media coverage by the Pew Research Center in Washington found.

The information is here.

Google’s AI ethics won't curb war by algorithm

Phoebe Braithwaite
Wired.com
Originally published July 5, 2018

Here is an excerpt:

One of these programmes is Project Maven, which trains artificial intelligence systems to parse footage from surveillance drones in order to “extract objects from massive amounts of moving or still imagery,” writes Drew Cukor, chief of the Algorithmic Warfare Cross-Functional Team. The programme is a key element of the US army’s efforts to select targets. One of the companies working on Maven is Google. Engineers at Google have protested their company’s involvement; their peers at companies like Amazon and Microsoft have made similar complaints, calling on their employers not to support the development of the facial recognition tool Rekognition, for use by the military, police and immigration control. For technology companies, this raises a question: should they play a role in governments’ use of force?

The US government’s policy of using armed drones to hunt its enemies abroad has long been controversial. Gibson argues that the CIA and US military are using drones to strike “far from the hot battlefield, against communities that aren't involved in an armed conflict, based on intelligence that is quite frequently wrong”. Paul Scharre, director of the technology and national security programme at the Center for a New American Security and author of Army of None says that the use of drones and computing power is making the US military a much more effective and efficient force that kills far fewer civilians than in previous wars. “We actually need tech companies like Google helping the military to do many other things,” he says.

The article is here.

A Son’s Race to Give His Dying Father Artificial Immortality

James Vlahos
wired.com
Originally posted July 18, 2017

Here is an excerpt:

I dream of creating a Dadbot—a chatbot that emulates not a children’s toy but the very real man who is my father. And I have already begun gathering the raw material: those 91,970 words that are destined for my bookshelf.

The thought feels impossible to ignore, even as it grows beyond what is plausible or even advisable. Right around this time I come across an article online, which, if I were more superstitious, would strike me as a coded message from forces unseen. The article is about a curious project conducted by two researchers at Google. The researchers feed 26 million lines of movie dialog into a neural network and then build a chatbot that can draw from that corpus of human speech using probabilistic machine logic. The researchers then test the bot with a bunch of big philosophical questions.

“What is the purpose of living?” they ask one day.

The chatbot’s answer hits me as if it were a personal challenge.

“To live forever,” it says.

The article is here.

Yes, I saw the Black Mirror episode using a similar theme.

This Suicide Pod Dubbed 'the Tesla of Death' Lets You Kill Yourself Peacefully

Loukia Papadopoulos
Interesting Engineering
Originally posted April 27, 2018

A new controversial pod for ending one’s life is on the market and it is being dubbed the Tesla of death and its founder, the Elon Musk of suicide. The pod, developed by euthanasia campaigner Dr. Philip Nitschke, is called the Sarco and it seeks to revolutionize the way we die.

The Sarco's website features a thought-provoking question on its landing page. “What if we had more than mere dignity to look forward to on our last day on this planet?” reads the site.

A description of the pod goes on to explain that “the elegant design was intended to suggest a sense of occasion: of travel to a ‘new destination’, and to dispel the ‘yuk’ factor.” If this sounds like a macabre joke, rest assured it is not.

The article is here.

The ethics of experimenting with human brain tissue

Nita Farahany, and others
Nature
Originally published April 25, 2018

If researchers could create brain tissue in the laboratory that might appear to have conscious experiences or subjective phenomenal states, would that tissue deserve any of the protections routinely given to human or animal research subjects?

This question might seem outlandish. Certainly, today’s experimental models are far from having such capabilities. But various models are now being developed to better understand the human brain, including miniaturized, simplified versions of brain tissue grown in a dish from stem cells — brain organoids. And advances keep being made.

These models could provide a much more accurate representation of normal and abnormal human brain function and development than animal models can (although animal models will remain useful for many goals). In fact, the promise of brain surrogates is such that abandoning them seems itself unethical, given the vast amount of human suffering caused by neurological and psychiatric disorders, and given that most therapies for these diseases developed in animal models fail to work in people. Yet the closer the proxy gets to a functioning human brain, the more ethically problematic it becomes.

The information is here.

What If There Is No Ethical Way to Act in Syria Now?

Sigal Samel
The Atlantic
Originally posted April 13, 2018

For seven years now, America has been struggling to understand its moral responsibility in Syria. For every urgent argument to intervene against Syrian President Bashar al-Assad to stop the mass killing of civilians, there were ready responses about the risks of causing more destruction than could be averted, or even escalating to a major war with other powers in Syria. In the end, American intervention there has been tailored mostly to a narrow perception of American interests in stopping the threat of terror. But the fundamental questions are still unresolved: What exactly was the moral course of action in Syria? And more urgently, what—if any—is the moral course of action now?

The war has left roughly half a million people dead—the UN has stopped counting—but the question of moral responsibility has taken on new urgency in the wake of a suspected chemical attack over the weekend. As President Trump threatened to launch retaliatory missile strikes, I spoke about America’s ethical responsibility with some of the world’s leading moral philosophers. These are people whose job it is to ascertain the right thing to do in any given situation. All of them suggested that, years ago, America might have been able to intervene in a moral way to stop the killing in the Syrian civil war. But asked what America should do now, they all gave the same startling response: They don’t know.

The article is here.

Did Iraq Ever Become A Just War?

Matt Peterson
The Atlantic
Originally posted March 24, 2018

Here is an excerpt:

There’s a broader sense of moral confusion about the conduct of America’s wars. In Iraq, what started as a war of choice came to resemble much more a war of necessity. Can a war that started unjustly ever become righteous? Or does the stain permanently taint anything that comes after it?

The answers to these questions come from the school of philosophy called “just war” theory, which tries to explain whether and when war is permissible, and under what circumstances. It offers two big ways to think about the justice of war. One is whether it’s appropriate to go to war in the first place. Take North Korea, for example. Is there a cause worth killing thousands—millions—of North and South Korean civilians over? Invoking “national security” isn’t enough to make a war just. Kim Jong Un’s nuclear weapons pose an obvious threat to South Korea, Japan, and the United States. But that alone doesn’t make war an acceptable choice, given the lives at stake. The ethics of war require the public to assess how certain it is that innocents will be killed if the military doesn’t act (Will Kim really use his nukes offensively?), whether there’s any way to remove the threat without violence (Has diplomacy been exhausted?), and whether the scale of the deaths that would come from intervention is truly in line with the danger war is meant to avert (If the peninsula has to be burned down to be saved, is it really worth it?)—among other considerations.

The other questions to ask are about the nature of the combat. Are soldiers taking care to target only North Korea’s military? Once the decision has been made that Kim’s nuclear weapons pose an imminent threat, hypothetically, that still wouldn’t make it acceptable to firebomb Pyongyang to turn the population against him. Similarly, American forces could not, say, blow up a bus full of children just because one of Kim’s generals was trying to escape on it.

The article is here.

Stop Posturing and Start Problem Solving: A Call for Research to Prevent Gun Violence

Kelsey Hills-Evans, Julian Mitton, and Chana Sacks
AMA Journal of Ethics. January 2018, Volume 20, Number 1: 77-83.
doi: 10.1001/journalofethics.2018.20.01.pfor1-1801.

Abstract

Gun violence is a major cause of preventable injury and death in the United States, leading to more than 33,000 deaths each year. However, gun violence prevention is an understudied and underfunded area of research. We review the barriers to research in the field, including restrictions on federal funding. We then outline potential areas in which further research could inform clinical practice, public health efforts, and public policy. We also review examples of innovative collaborations among interdisciplinary teams working to develop strategies to integrate gun violence prevention into patient-doctor interactions in order to interrupt the cycle of gun violence.

An Ethical Obligation to Address Gun Violence

More than twenty survivors of the Pulse nightclub massacre traveled together to Boston, Massachusetts, in the days before the one-year anniversary of that horrific night. They met with a group of physicians, nurses, social workers, administrators, and others at our hospital to talk about their experience. They recounted their memories of the sounds of gunfire, the screams of those around them, and the moans from those felled beside them. They described the ups and downs that have characterized their attempts to rebuild in the year since gunfire shattered their sense of normalcy. They shared their stories in the hopes that if more people could understand what it means to be affected by gun violence, then we, as a nation, would be compelled to act.

The article is here.

This Cat Sensed Death. What if Computers Could, Too?

Siddhartha Mukherjee
The New York Times
Originally published January 3, 2017

Here are two excerpts:

But what if an algorithm could predict death? In late 2016 a graduate student named Anand Avati at Stanford’s computer-science department, along with a small team from the medical school, tried to “teach” an algorithm to identify patients who were very likely to die within a defined time window. “The palliative-care team at the hospital had a challenge,” Avati told me. “How could we find patients who are within three to 12 months of dying?” This window was “the sweet spot of palliative care.” A lead time longer than 12 months can strain limited resources unnecessarily, providing too much, too soon; in contrast, if death came less than three months after the prediction, there would be no real preparatory time for dying — too little, too late. Identifying patients in the narrow, optimal time period, Avati knew, would allow doctors to use medical interventions more appropriately and more humanely. And if the algorithm worked, palliative-care teams would be relieved from having to manually scour charts, hunting for those most likely to benefit.

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So what, exactly, did the algorithm “learn” about the process of dying? And what, in turn, can it teach oncologists? Here is the strange rub of such a deep learning system: It learns, but it cannot tell us why it has learned; it assigns probabilities, but it cannot easily express the reasoning behind the assignment. Like a child who learns to ride a bicycle by trial and error and, asked to articulate the rules that enable bicycle riding, simply shrugs her shoulders and sails away, the algorithm looks vacantly at us when we ask, “Why?” It is, like death, another black box.

The article is here.

Death and the Self

Shaun Nichols, Nina Strohminger, Arun Rai, Jay Garfield
Cognitive Science (2018) 1–19

Abstract

It is an old philosophical idea that if the future self is literally different from the current self,
one should be less concerned with the death of the future self (Parfit, 1984). This paper examines
the relation between attitudes about death and the self among Hindus, Westerners, and three Buddhist
populations (Lay Tibetan, Lay Bhutanese, and monastic Tibetans). Compared with other
groups, monastic Tibetans gave particularly strong denials of the continuity of self, across several
measures. We predicted that the denial of self would be associated with a lower fear of death and
greater generosity toward others. To our surprise, we found the opposite. Monastic Tibetan Buddhists
showed significantly greater fear of death than any other group. The monastics were also
less generous than any other group about the prospect of giving up a slightly longer life in order
to extend the life of another.

The article is here.

Drug Companies’ Liability for the Opioid Epidemic

Rebecca L. Haffajee and Michelle M. Mello
N Engl J Med 2017; 377:2301-2305
December 14, 2017
DOI: 10.1056/NEJMp1710756

Here is an excerpt:

Opioid products, they alleged, were defectively designed because companies failed to include safety mechanisms, such as an antagonist agent or tamper-resistant formulation. Manufacturers also purportedly failed to adequately warn about addiction risks on drug packaging and in promotional activities. Some claims alleged that opioid manufacturers deliberately withheld information about their products’ dangers, misrepresenting them as safer than alternatives.

These suits faced formidable barriers that persist today. As with other prescription drugs, persuading a jury that an opioid is defectively designed if the Food and Drug Administration approved it is challenging. Furthermore, in most states, a drug manufacturer’s duty to warn about risks is limited to issuing an adequate warning to prescribers, who are responsible for communicating with patients. Finally, juries may resist laying legal responsibility at the manufacturer’s feet when the prescriber’s decisions and the patient’s behavior contributed to the harm. Some individuals do not take opioids as prescribed or purchase them illegally. Companies may argue that such conduct precludes holding manufacturers liable, or at least should reduce damages awards.

One procedural strategy adopted in opioid litigation that can help overcome defenses based on users’ conduct is the class action suit, brought by a large group of similarly situated individuals. In such suits, the causal relationship between the companies’ business practices and the harm is assessed at the group level, with the focus on statistical associations between product use and injury. The use of class actions was instrumental in overcoming tobacco companies’ defenses based on smokers’ conduct. But early attempts to bring class actions against opioid manufacturers encountered procedural barriers. Because of different factual circumstances surrounding individuals’ opioid use and clinical conditions, judges often deemed proposed class members to lack sufficiently common claims.

The article is here.

Suicide Is Not The Same As "Physician Aid In Dying"

American Association of Suicidology
Suicide Is Not The Same As "Physician Aid In Dying"
Approved October 30, 2017

Executive summary 

The American Association of Suicidology recognizes that the practice of physician aid in dying, also called physician assisted suicide, Death with Dignity, and medical aid in dying, is distinct from the behavior that has been traditionally and ordinarily described as “suicide,” the tragic event our organization works so hard to prevent. Although there may be overlap between the two categories, legal physician assisted deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.

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Conclusion 

In general, suicide and physician aid in dying are conceptually, medically, and legally different phenomena, with an undetermined amount of overlap between these two categories. The American Association of Suicidology is dedicated to preventing suicide, but this has no bearing on the reflective, anticipated death a physician may legally help a dying patient facilitate, whether called physician-assisted suicide, Death with Dignity, physician assisted dying, or medical aid in dying. In fact, we believe that the term “physician-assisted suicide” in itself constitutes a critical reason why these distinct death categories are so often conflated, and should be deleted from use. Such deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.

The full document is here.

New York’s Highest Court Rules Against Physician-Assisted Suicide

Jacob Gershman
The Wall Street Journal
Originally posted September 7, 2017

New York’s highest court on Thursday ruled that physician-assisted suicide isn’t a fundamental right, rejecting a legal effort by terminally ill patients to decriminalize doctor-assisted suicide through the courts.

The state Court of Appeals, though, said it wouldn’t stand in the way if New York’s legislature were to decide that assisted suicide could be “effectively regulated” and pass legislation allowing terminally ill and suffering patients to kill themselves.

Physician-assisted suicide is illegal in most of the country. But advocates who support loosening the laws have been making gains. Doctor-assisted dying has been legalized in several states, most recently in California and Colorado, the former by legislation and the latter by a ballot measure approved by voters in November. Oregon, Vermont and Washington have enacted similar “end-of-life” measures. Washington, D.C., also passed an “assisted-dying” law last year.

Montana’s highest court in 2009 ruled that physicians who provide “aid in dying” are shielded from liability.

No state court has recognized “aid in dying” as a fundamental right.

The article is here.

Peter Thiel sponsors offshore testing of herpes vaccine, sidestepping U.S. safety rules

Marisa Taylor
Kaiser News
Originally posted August 28, 2017

Here is an excerpt:

“What they’re doing is patently unethical,” said Jonathan Zenilman, chief of Johns Hopkins Bayview Medical Center’s Infectious Diseases Division. “There’s a reason why researchers rely on these protections. People can die.”

The risks are real. Experimental trials with live viruses could lead to infection if not handled properly or produce side effects in those already infected. Genital herpes is caused by two viruses that can trigger outbreaks of painful sores. Many patients have no symptoms, though a small number suffer greatly. The virus is primarily spread through sexual contact, but also can be released through skin.

The push behind the vaccine is as much political as medical. President Trump has vowed to speed up the FDA’s approval of some medicines. FDA Commissioner Scott Gottlieb, who had deep financial ties to the pharmaceutical industry, slammed the FDA before his confirmation for over-prioritizing consumer protection to the detriment of medical innovations.

“This is a test case,” said Bartley Madden, a retired Credit Suisse banker and policy adviser to the conservative Heartland Institute, who is another investor in the vaccine. “The FDA is standing in the way, and Americans are going to hear about this and demand action.”

American researchers are increasingly going offshore to developing countries to conduct clinical trials, citing rising domestic costs. But in order to approve the drug for the U.S. market, the FDA requires that clinical trials involving human participants be reviewed and approved by an IRB or an international equivalent. The IRB can reject research based on safety concerns.

The article is here.