Dr. Andy

Reflections on medicine and biology among other things

Friday, October 21, 2005

Capitalism and medicine

I am a capatilist at heart. Self-interested actors leading unwittingly to the overall good, the invisible hand et al. I'm a believer. But there seem to be instances in which everyone acting in their own interest doesn't benefit patients. In yesterday's NYT is an article about failures in a particular brand of defibrillators which are implanted into the hearts of patients at high risks of arrythmias (abnormalities of the hearts rhythym) such as our vice-president, Dick Chaney, and Joshua Oukrop, a young man with a congenital defect, hypertrophic cardiomyopathy, that caused his heart muscle to grow too thick. Unfortunately, his defibirllator shorted out and he died, an apparently frequent occurence with this specific model of Guidant defibrillator.
Two months after Mr. Oukrop's death, the Guidant Corporation, the country's second-biggest maker of heart defibrillators, acknowledged that it had not told doctors for three years that one model had short-circuited in about two dozen cases, including the one involving him.
The article is good, read it all. The hard thing is you can understand why Guidant didn't want to step forward earlier, all the incentives were to do nothing. Same thing with Merck and Vioxx.

I don't know the answer to this, but I do know a more rationally designed health care system will have to take these kinds of things into account.

I suppose the other side of the coin is that maybe the system is okay: many more people would have died if it had taken even longer for these things to come out. Maybe some combination of lawsuits, doctors who want to be whistleblowers and regulation is actually pretty good at picking up these sort of dangers, just not perfect, and we are focusing too much on the failures.

One thing that is clearly misguided is allowing the companies themselves to be in charge of post-marketing surveillance:

Guidant executives like Mr. McCoy have insisted that their decisions about when to disclose product defects were not affected by financial factors, like the pending Johnson & Johnson deal. Guidant said that as with the Prizm 2 DR, the rate of failure of the Contak Renewal was not high enough to meet the company's criteria for notifying doctors.

"At this company, the quality culture is absolutely apparent," Mr. McCoy said in his July interview with the Minneapolis Star Tribune.

Others are skeptical. "I think J.& J. colored things," said Dr. Hauser of Minneapolis.

Whether the company was influenced by financial concerns or not, it surely appears they would be. Some sort of independent board monitoring adverse effects would be free of those pressures.


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