Philosophers On Access to Medicine

Three philosophers discuss some of the moral and political questions involved in providing access to medicine and medical care in this edition of Philosophers On.

[Damien Hirst, “Utopia”]

During the pandemic, the problem of lack of access to medicine, treatments, medical equipment, and care was made vividly personal to a large number of people who otherwise have the privilege of not having to worry about it. To Nicole Hassoun, professor of philosophy at Binghamton University, this seemed like an opportunity to draw attention to those people around the world who do regularly have to worry about this problem, and the questions and challenges that arise in devising a better and fairer distribution of access to medicine. She contacted some other philosophers who work on these matters and the result is this post, with contributions by her, Govind Persad, assistant professor at the Sturm College of Law at the University of Denver, and Anders Herlitz, associate professor of philosophy at the Institute for Futures Studies at Stockholm University.

The Philosophers On series contains group posts on issues of current interest, with the aim being to show what the careful thinking characteristic of philosophers (and occasionally scholars in related fields) can bring to popular ongoing conversations. Contributors typically present not fully worked out comprehensive positions but rather relatively brief thoughts that can serve as prompts for further reflection and discussion.

Thanks to Professor Hassoun for putting this together and to Professor Herlitz and Professor Persad for taking part. The individual contributions are below.

  1. “Medicine and the Global Health Impact Project” by Nicole Hassoun
  2. “How to Care About Life Expectancy” by Anders Herlitz
  3. “What Sort of Access to Which Medicines?” by Govind Persad

Medicine and the Global Health Impact Project
by Nicole Hassoun

As the Coronavirus pandemic surges around the world, for the first time, many people in developed countries realize what it means to lack access to essential medicines. Must governments, the international community, or pharmaceutical companies extend access to these medicines around the world and, if so, how should they do so?

In the United States, the idea that people have a right to health is controversial. People generally need private health insurance to access adequate care, and although we’ve seen some changes in recent years, the legal right to health articulated in international law is not one that the United States has fully endorsed.

In my book, Global Health Impact: Extending Access to Essential Medicines , I defend the idea that everyone should (morally) have this legal right to health, it should be enforced, and people should be able to access essential medicines as one part of that right. I believe that the right is justified because it protects everyone’s ability to live, what I refer to as, a minimally good life. As I believe the human right to health is articulated in an international law, different agents have different obligations to help people secure access to medicines. In the book, I also argue that human rights should inspire us to think creatively about how to better meet everyone’s basic health needs. I believe that these arguments can guide our response to the COVID-19 pandemic and help us better prevent and address other health crises.

The human right to health should, and often does, give rise to a virtue I call creative resolve,a fundamental commitment to overcoming apparent tragedy. This right helps us respond to a mindset focused on scarcity, which necessitates rationing essential resources, such as medicines.

One of the most prominent objections to a legal human right to health, at least in the United States, and in the philosophical literature, is that it is unrealistic. One worry is that, if we must help everyone secure a basic minimum of health, there is not much else we will be capable of doing. Moreover, people have other rights (e.g. a right to education), and this requires us to consider trade-offs between fulfilling these rights. I believe this depends on how you perceive the human right to health and the obligations it generates with respect to other competing obligations. However, I do not think we should reject a legal human right to health because it is expensive or because we need to ration health care. The right to health can, and should, do something much more important for us: It should inspire us to find new ways of fulfilling the right and, thus, help reduce the need to ration.

I believe commitment to the human right to health can help us extend access to healthcare significantly. I follow Amartya Sen who says that when we think of health as a human right, that is a call to action to advance people’s health now in the way 18th century activists fought for freedom and liberty. So, when I talk about the virtue of creative resolve—that fundamental commitment to trying to fulfill the right insofar as possible and permissible—it takes into account other things that matter. And more specifically, it requires us to do things like question evidence that we cannot fulfill the right, seek out creative ways of doing so, and act to fulfill it.

Consider the fight to extend access to essential medicines for AIDS. By the 1990s, people in Europe and the US were living long and healthy lives due to antiretroviral drugs, but around the world, millions of people still couldn’t access those medicines and were dying from the disease. The cost of antiretrovirals was about $12,000 per patient per year and pharmaceutical companies claimed it was impossible to lower the prices. But human rights activists refused to accept this claim. They were going to find ways of making access to medicines possible and they came up with creative ways of extending access. They galvanized a global movement to do that by educating patients about their rights and shifting public opinion on access to help bring that price down from $12,000 per patient per year to about $350 per patient per year. The history of public health is replete with similar stories about the fight against other diseases like smallpox, polio, Ebola and tuberculosis.

There are many creative proposals for extending access to essential medicines around the world – including proposals to incentivize new innovation and proposals to extend access to existing drugs and technologies. We require a broad array of different possible solutions to ensure solving the access to medicines problem.

My own attempt to think creatively about how to extend access to essential medicines around the world is an initiative called the Global Health Impact Project (GHI). The intention of GHI is to incentivize positive change by evaluating the health consequences of medicines for some of the world’s worst diseases. I launched the scientific part of this project at the World Health Organization in 2015 and relaunched some of our newer models at Princeton University last year. Having this information can help de-link pharmaceutical companies’ incentives from profits and encourage them to focus on alleviating the greatest amount of need possible. We can encourage companies to save more lives and alleviate more disability using data by tying existing proposals for extending access to requirements to increase Global Health Impact (e.g. advance market commitments can be based on the health impact of resulting innovations). In the book, I discuss how consumers can use the information from this index to decide which products to purchase. So if you have two otherwise equivalent products from two different companies and one of those companies is having a great Global Health Impact with their medicines, you might reasonably prefer to purchase things from that company, you can think of it like fair trade for global health. Companies care about their reputations and could profit from these labels. Socially responsible investors might also care about companies’ Global Health Impact – for some time, Sanofi was using our label, along with other rating systems, on their website. Universities also produce a lot of the drugs and technologies that companies rely on, so if universities made it a condition of the sale of their licenses that companies have a high Global Health Impact, that could also make a difference. Together these ideas might create incentives for companies to get themselves highly rated, and these incentives may equate to better access to essential medicines.

Policy makers can also tie the Global Health Impact measurement to things like global prize funds. If you reward companies for new innovations based on their Global Health Impact, that gives them an incentive to focus on diseases such as AIDS, malaria, and TB that are causing death and disability around the world, and less to catering to rich patients, which is currently their most lucrative option. Policy makers can also use the Global Health Impact Index in thinking about restructuring laws such as the Orphan Drug Act, which gives companies a large incentive to create drugs that do not have a large market in the US. It could be useful to reward companies for these new innovations only in proportion to their Global Health Impact.

Finally, I think information on Global Health Impact is important for health systems planning and resource distribution. The World Health Organization, the TB Alliance, USAID and other health organizations need to know where they are having an impact and where they are not, to set targets, measure progress, and improve health.

When it comes to the Coronavirus, I think some of these proposals can help. Now is a good time to radically restructure the incentives for pharmaceutical research and development, there simply should not be any patents in a pandemic. 80% of manufacturing capacity is for generics, we cannot use this capacity if we let companies maintain patents on their products. We should instead reward them on the basis of total Global Health Impact. And, if we cannot do that, we should find other creative ways to help everyone secure the medicines they need, by joining the COVAX initiative, doing compulsory licensing, and employing other innovative proposals for helping people access essential medicines now.

(This post draws on the New Books in Medicine podcast on the book that may be of interest to readers, as well as ideas in several op eds.)

How to Care about Life Expectancy
by Anders Herlitz

The COVID-19 pandemic actualizes philosophical questions about whether life expectancy matters when one must choose which life to save when not everyone can be saved. Such choice situations might arise when intensive care units are overcrowded, when therapeutics such as remdesivir are scarce and when scarce vaccines are distributed. I will here suggest that life expectancy does matter, but that it matters in a clumpy way.

Consider the following situation:

Big Difference: Two 50-year-old men, Charles and David, urgently need a life-saving treatment for a health problem they are not responsibility for and are expected to die in 3 weeks if they do not get the treatment. However, there is only one treatment available. If Charles receives the treatment, he is expected to live a life of good health for another 10 years. If David receives the treatment, he is expected to die in 4 weeks from unrelated health problems.

I believe that in this situation, one should save Charles’s life and the fact about the situation that leads to that conclusion is that Charles’s life expectancy is significantly greater than David’s.

Several ethical theories pick up on this factual difference between Charles and David and refer to it in order to support this conclusion. Here are three appealing ethical approaches that do that:

Consequentialist approaches
Consequentialist theories (e.g. utilitarianism, prioritarianism) say that you ought to do that which has the best consequences. These theories typically satisfy anonymity axioms so that it does not matter who enjoys what benefits. Insofar as one accepts that it is a good thing that someone lives between the age 50 and 60, it has better consequences to save Charles. From a consequentialist perspective, the only relevant difference between saving Charles and David is that saving Charles amounts to an outcome where one person dies at age 60 and another person dies at age 50 + 3 weeks, while saving David amounts to an outcome where one person dies at age 50 + 4 weeks and another person dies at age 50 + 3 weeks.

According to contractualism, one ought to follow the principle which no one can reasonably reject. A popular contractualist idea is that: “an individual can reasonably reject a principle if her level of well-being and burden, given widespread acceptance of that principle over her lifetime, combine into a complaint greater than that had by anyone else about some alternative principle, given widespread acceptance of that alternative over a lifetime. (Reibetanz 1998: 300)”

The largest complaint that can be charged against a principle that says one should be indifferent toward saving Charles or David is plausibly equal to David’s prospective loss (assuming you flip a coin, 0.5 * 10 years). The largest complaint that can be charged against a principle that says one should save the person with greatest life expectancy is equal to Charles’s loss (i.e. 1 week). The strongest complaint against a principle that recommends saving the person with the greatest life expectancy is the smallest (1 week vs. 5 years).

Harm-based approaches
According to the so-called deprivation account of the badness of death, dying is bad because and to the extent that it deprives a person of something. The more it deprives someone of, the worse the death. It is worse to be deprived of 10 years of living than to be deprived of 1 week of living. Paired with the idea that one ought to prevent the biggest harm possible, the deprivation account of the badness of death favors saving Charles.

However, as appealing as these approaches might be, they seem to generate unpalatable recommendation in other cases. Consider:

Small Difference: Two 50-year-old men, Eric and Fred, urgently need a life-saving treatment for a health problem they are not responsibility for and are expected to die in 3 weeks if they do not get the treatment. However, there is only one treatment available. If Eric receives the treatment, he is expected to live a life of good health for another 10 years. If Fred receives the treatment, he is expected to live a life of good health for another 10.1 years.

I propose that in this situation—contrary to what the approaches outlined above seem to suggest—it is not at all obvious that one should save Fred’s life based on the fact that his life expectancy is greater than Eric’s. By contrast, I think that it is appropriate to give both Eric and Fred some chance of receiving the treatment in this case. Fairness requires that we treat roughly similar claims in similar ways.

To account for the intuitions that at least I have in Big Difference and Small Difference, one needs a principle that allows for differences in life expectancy to guide action in some but not all cases, i.e. the principle must accept clumpiness regarding the value of saving lives with different life expectancy. Here is one such principle:

Clumpy Maximization: If and only if one of the available acts, a, saves a life with significantly longer life expectancy (if saved) than any of the lives that otherwise could be saved, then there is a pro tanto reason to do a.

Applied to healthcare policy and choice situations actualized by a pandemic, Clumpy Maximization does not say that healthcare practitioners and distributors of scarce health-related resources make fine-grained assessments of what patients would live longer if their lives were saved. In this way, it is—presumably—less controversial than some alternative principles that ascribes importance to life expectancy. At the same time, Clumpy Maximization does say that when the choice is between someone with a potentially long future ahead of them and someone with a relatively short future ahead of them, there is a reason to save the person with the greatest life expectancy, which is something I believe any plausible approach really must imply.

Much more must of course be said about how to operationalize and interpret Clumpy Maximization. What counts as “significantly” longer? What should be done when there is no significant difference in life expectancy? How should the principle be applied to large choice sets? Does it—as I suspect—run into problems with rationality requirements? What should be done if that happens? And how strong is the reason to save the life with the longest life expectancy? How does this reason compare to other possibly valid considerations that have been set aside by the set-up of Big Difference and Small Difference but might be relevant? For instance, there might be reasons to prioritize significantly younger patient, there might be reasons to save the greater number of lives, and there might be reasons to maximize positive aggregate health impact more generally (i.e. taking into account both lives saved and other health impact). How does the reason expressed in Clumpy Maximization compare to these considerations?

What Sort of Access to Which Medicines?
by Govind Persad

Two issues are central to the ethics of access to medicines. First, defining access and understanding tradeoffs between different types of access. Second, understanding which medicines should be understood as essential and how increasing access to some medicines might compete with increasing access to others.

Access, Availability, and Affordability

One dimension of access is availability: whether a given medicine is developed and sold. Another is affordability: whether people can afford to purchase the medicine without financial hardship.

Affordability depends on three factors: (1) the funds available to the buyer, (2) financial help from third parties like health insurers, governments, or NGOs, and (3) the price charged by the seller. A generic statin for high cholesterol that costs $1 a day may be affordable for most people in Switzerland or Japan, but not for most in Mali or Turkmenistan.

Policy choices can affect each of these variables, and each presents trade-offs. Policymakers can relieve the burden on buyers by having third parties pay part of the price sellers charge. They can do this by mandating that insurers cover certain medicines, or by directly paying for some medicines. The merits of third party payments depend on their opportunity costs and on the incentives they create. For instance, when policymakers mandate coverage, they create incentives—sometimes unintended ones—to develop drugs that insurance will cover. Policymakers could also try to improve buyers’ purchasing power through cash transfers or programs to increase wages. But unlike with third-party payment, buyers might elect to spend these funds on something other than medicine–food, shelter, education, or leisure—which might improve well-being but not access to medicines.

Second, policymakers can work to lower the prices sellers charge for medicines. They can do so by direct price regulation; by shortening patent terms, weakening IP protections, or removing other barriers to market entry; or by providing incentives for lower pricing. Lowering prices has the potential consequence of decreasing availability, because firms may be less willing to invest in developing drugs if they will be unable to charge high prices for them. Nevertheless, affordable access to a smaller menu of medicines may be preferable to the formal availability of a larger menu of medicines. Efforts to lower prices may be especially justifiable when they serve to encourage the development of medicines with more social value, discussed next.

Which Medicines are Essential?

Many fundamental needs are universal. Everyone needs clean water. Everyone needs food with essential nutrients and shelter to protect them from the elements. While there are cultural differences in the foods people eat and the style of shelter they prefer, most people can benefit from most food and shelter. A Swiss family could safely shelter from a storm in a Malian mudbrick house and obtain nutrition by eating millet for breakfast; a Malian family could safely shelter in a stone house and eat muesli.

Some medicines are like food or water—valuable for, and essential to, everyone. Almost everyone, during their lives, will need and benefit from medicines that treat pain, such as acetaminophen, or address ubiquitous illnesses, such as vaccinations against diseases like measles and antibiotics that treat infection.

But many medicines are essential for some people but not others. A dose of insulin that would be dangerous for most can be a necessity for some with diabetes. Chemotherapeutic drugs are toxic but can help cure cancer. Coagulation factor, which can cost more than $100,000 per year for people with hemophilia, is not helpful for those whose blood clots naturally.

The heterogeneity of medical needs makes defining essential medicines challenging. One place to start might be with medicines, like antibiotics, vaccines, and analgesics, that meet universal needs, with a special emphasis on medicines that help meet urgent needs in more disadvantaged settings. Although the World Health Organization is not explicit about how they develop their essential medicines list, their criteria combine broad benefits with affordability. Many developed countries, including Sweden and New Zealand, also provide a defined list of essential medicines in order to effectively negotiate for affordable access.

Current economic incentives for pharmaceutical innovation, however, do not match up well with a plausible definition of essential medicines. This is especially clear for antibiotics and vaccines, which are recognized as areas of underinvestment even though innovations in these areas would have enormous and widely dispersed benefits, as the example of a COVID-19 vaccine shows. Instead, current incentives encourage innovation that benefits people with greater ability to pay, or that insurers will reimburse more generously. Many countries even encourage developing medicines that will benefit fewer people, by treating less common diseases, rather than aiming to benefit more people by improving treatment for widespread conditions.

As I argue elsewhere, policies for access to medicines such as value-based price regulation would encourage the development and provision of medicines whose benefits are greater and more broadly shared, especially those that better or more cheaply prevent and treat conditions—like malaria, tuberculosis, and HIV infection—that are particularly widespread among disadvantaged people. So might other approaches like prizes.

Because medical needs are so variable, no definition of essential medicines, short of one that encompasses every medicine that could ever help anyone, will meet everyone’s needs. But policies that incentivize meeting more needs and meeting the needs of the least advantaged are a reasonable place to start. As Paul Farmer observes, “dying of never-treated AIDS in a dirt-floored hut in Africa is worse than dying of AIDS in a comfortable hospice in Boston after having failed a decade of therapy.” This is even truer when we compare interventions that benefit more people to those that benefit fewer: for instance, a vaccine that could prevent cervical cancer for thousands of people around the world versus a $32,000/month chemotherapeutic that extends life by less than a year for patients with a rare cancer. No plausible ethical theory regards the second treatment as more important to make available than the first. Yet current incentives for access to medicines too often do.

Discussion welcome.

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