By Mark Robinson and Joseph M. Gabriel
In a previous post, one of us has argued that bioethical deliberation needs to incorporate an analysis of “market forces in health-related decision-making” under what might be called “economic bioethics.”
To a certain extent, of course, bioethicists already do this. Industry-physician relations, for example, attracts substantial attention from the field. Other notable topics include the price of health-care services and technologies (and drugs in particular), patenting biological material, debates about funding controversial types of medical research, and debates about the allocation of resources during times of scarcity.
These are just some examples of how bioethicists regularly engage in topics that lay at the intersection of market forces and both clinical reasoning and research practices. Given this, what does it mean to call for greater attention to the role of market forces in bioethics?
Our answer cannot be simply that bioethicists should study market forces. Numerous fields already engage with questions about how economic imperatives interact with medical decision making – including fields as diverse as medical anthropology, medical sociology, health economics, and the history of science, technology, and medicine. What, then, does it mean to call for an economic bioethics? What does bioethics bring to the table that these other fields do not? Lastly, what necessitates this shift within bioethics?
Not surprisingly, part of the answer to these questions lays in the fact that medical ethics – or, at least, a significant portion of the field – deals with what clinicians and researchers actually do. As a field, bioethics tends to focus on two overlapping areas: clinical decision making and research ethics in the biomedical sciences. In both cases much of the field focuses on normative questions that are “close to the ground,” so to speak.. Bioethics thus traces the gaps that emerge from normative ideals of care and the actual “on the ground reality” therein. Thus, while seeking consent is an important ethical ideal, chronic provider understaffing makes the reality far less ideal on the ground. Bioethical deliberation that engages with questions related to market forces frequently exhibit this tendency – is it ethical to accept funding from industry, for example, and what rules should guide such decisions? Who should receive costly treatments when resources are scarce? Is it ethical to recommend very costly experimental treatments?
These and numerous other questions engage problems that are clearly related to market forces, but they do so in a way that generally consider these issues as large and structural and thus, outside the domain of deliberation. Standard analyses also tend to focus on individual behaviors and decision-making. As a result, large structural questions get bracketed as important and interesting areas of inquiry, perhaps, but not as directly relevant to the normative questions regarding what clinicians and research scientists should actually do or what responsibilities are owed to patients. In a later post, one of us will explore some of the consequences of the person-centered focus in bioethics.
In a similar manner, bioethical deliberation that does focus on broader questions – critique of pharmaceutical company behavior, for example, or debate about patenting and the relationship between innovation, drug patents, and drug prices – are often detached from normative claims that bioethics makes regarding on-the-ground practices. Does the fact that the drug industry has repeatedly engaged in fraudulent behavior really matter when it comes time for research scientists to decide whether or not to accept an industry grant? company? Does it matter whether or not patents stimulate drug innovation when a physician is faced with a sick patient and trying to decide what to do? If we are to believe the current literature the answer is: apparently not. While bioethics regularly draws from empirical research to make moral claims (for example, about the effectiveness of screening tests), overwhelming evidence about market-driven R&D decisions does not make it into bioethical recommendations.
Obvious exceptions exist. Bioethical critique of the drug industry, for example, has helped fuel a growing skepticism toward the industry that has resulted in a growing number of physicians who refuse to allow drug reps into their offices – a practice that is, in turn, linked to changes in prescribing behavior and legislative changes.
Yet, the promise of an “economic bioethics” lay in bringing these two domains together. In other words, an economic bioethics would illuminate how large, structural changes – financialization, for example, or market consolidation, or trade liberalization – increasingly structure both clinical decision making and the decisions of individual scientists on the ground. It would examine how market conditions continually produce ethical challenges that compel bioethical reflection. To do this, bioethicists should consider collaborating with researchers from other fields who have expertise in these types of questions. Doing so will help ethicists tackle questions that directly engage broad, structural issues that extend far beyond the clinic and the laboratory.
An economic bioethics, however, would not replicate these other fields. Bioethical deliberation is an explicitly normative domain, and as such can operate in productive tension with fields such as history, sociology, and anthropology, which are largely descriptive in nature and often exhibit a discomfort with explicitly normative claims.
Indeed, an economic bioethics would work to integrate descriptive analysis of broad structural processes and how they relate to clinical knowledge and research practices with an explicitly normative project of asserting what clinicians and researchers should actually do given the changing context in which they find themselves.
Thus, an economic bioethics would map the ways that markets are implicated in the growing gap between ethical ideals and pragmatic realities, effectively transforming practices of care for patients, and transforming the very contexts that give rise to provider and patient options. There is also some evidence of market-related factors changing ethical norms – the way that market pressures increase makes observing ethical practices (such as explaining procedures to patients as part of the content process) impractical.
Lastly, as an example of what we are thinking, consider the question of pharmaceutical industry corruption and clinical decision making. A significant body of both legal evidence and research from a variety of fields has documented how the drug industry has distorted scientific knowledge about a disturbingly large number of pharmaceuticals. Yet there has been little bioethical deliberation about what the widespread corruption of the scientific literature means in terms of actual clinical decision making practices. How should a clinician evaluate treatment options and recommendations when it is known that the advisory body making the recommendations has been financially supported by industry? What should physicians do when a scientific article they have used to make a clinical decision – with good results – is shown to be based on fraudulent practices?
An economic bioethics might tackle such questions by combining an analysis of the types of forces that have led industry to engage in unethical practices with normative claims about how clinicians should respond in the clinical context. The broad structural issues are not of secondary importance here. Understanding and describing them would be an essential component of the normative claims that are made.
Given the rise of the increasingly financial character of ethical problems requiring bioethical reflection, the need for an economic bioethics has never been more paramount.