On Epstein v. Relman (& Public Health Policy)

Howard Brody (the Director of the Institute for Medical Humanities, where I am a graduate student), has an interesting take on the kerfuffle between Richard Epstein and Arnold Relman regarding the former's new book, Overdose.

Brody notes:

Relman beats up on Epstein for two cardinal sins. First, Epstein is a frequent consultant for the drug industry and is also an economic disciple of Milton Friedman. Second, Epstein is a lawyer writing about health care matters. Both sins show that he is an idiot and that he cannot possibly therefore be correct about anything further.

Epstein replies in kind. Since Relman is a physician without any additional training, he clearly knows nothing about law, or economics, or corporations, so he's incompetent to pass judgment on any of these issues. And since Relman rejects Friedman, he must be an unreconstructed New Dealer (proof: he was born in 1923!) and is therefore completely unreliable on anything related to either economics or government.

Just how this pissing contest is supposed to enlighten the rest of us is never explained by either party.

A pox on both their houses?

Fortunately this is not about keeping score. It is about figuring out these thorny policy issues, and we cannot do so if we have a cardboard caricature of free-market worship on one side, and a cardboard caricature of anti-free-market attack on the other.

Instead, read two different books. First read Medicine and the Market by Callahan and Wasunna. You will find a careful analysis of both the ethics and the facts related to markets as a means of organizing medical care.

[ . . . ]

Next, read Leonard Weber's Profits Before People? Weber (an esteemed colleague of mine, who taught at University of Detroit-Mercy) has taught and written about business ethics in health care. His book on the pharmaceutical industry could be viewed as an ethics consultation, as if the industry had noted its poor PR lately and asked Weber for his ethical advice.

Recommended!

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I recently read Medicine and the Market.  It's an excellent book, chock full of facts and valid arguments, but it does eventually advance the triumphalist claim that biologics must be a keystone in any health reform program, particularly in developing countries.  This is somewhat odd given that there is ample reason to doubt that pharmaceuticals -- as important as they might be -- have anywhere near the effect on population health, particularly in developing countries, as public health and preventive medicine measures.

Even more strange, Callahan and Wasunna cite the well-known evidence for this proposition, but then proceed to advance their claim on the primacy of pharmaceuticals. 

It may or may not be relevant that Wasunna, an accomplished scholar and an authority on health policy in developing countries, is an assistant director of International Programs for Pfizer, Inc.

In any case, this is not an argument against biologics per se, but a policy argument for priority-setting, and a suggestion that both OECD and developing countries might be better served by funnelling a larger percentage of health care resources to public health and preventive medicine than to biologics.  Such an argument does not deny the significance of pharmaceuticals, but simply contends that its importance to overall population health must be relativized to other health care policies.