1. Health Care Industry Medical-industrial complex The industry that supplies healthcare for a profit Response to the opportunity to make large profits from the ill health of others 600 billion dollar industry in US alone (2009)

2. Medicine Is medicine a business or a profession? Make money and is organized around fees for service business model (indemnified) Makes new products and services only if profit is possible Markets and Media blitzes AND provides health and medical care

3. Industry Began as a cottage industry of offices with little horizontal or vertical integration Hospitals allowed for organization and integration Insurers and payers gained control and increased profit motive activity Now vertical and horizontal integration

4. Technology Makes the cost higher—DOES NOT NECESSARILY IMPROVE OUTCOMES Forgotten art of examination and history taking More scientific precision and more trust in result Complicates the Doctor-patient relationship

5. Industry of Medicine Commercialization Market-orientation Competition Threat to Moral Professional power base threat to social contract—patient gives power to doctor to diagnose and treat and doctor agrees to care and be altruistic

6. Do No Harm—A Moral Obligation Hippocratic oath Mission statements Malpractice law as check on obligation If we have no contract to care, then less trust— poor morale of doctors and harm more likely

7. Specialization of care Based on technology Example of heart centers and other centers of excellence Market oriented More money CCUs and ICUs cost more and have shiny technology—do they improve outcomes?

8. Special care units Borne of the research that was designed to improve outcome Little objective research of effectiveness Is it ethical to do a blinded study and sort LIVES into experimental groups when lives are what is at stake?

9. Technology and ethics Must control the technology not let it control us Personal autonomy depends on full information and consent Requires physician to be ethicist and doctor Requires the patient to be competent and knowledgeable

10. Do we need the technology? Simple measures most effective Old drugs less costly and more effective Prevention and health augmentation Public health Chronic disease and longevity

11. End of life issues Technology can continue mechanistic “life” almost indefinitely What is life? What is quality of life? Why quantity over quality—issue of uncertainty

12. Autonomy At end of life requires preplanning and commitment to thought and action in specific ways Requires knowledge (Foucault) Power is Knowledge

13. Marx and technology Unlikely that Marx intended the technology of medicine to be fitted to his ideas on stratification Is the tech available without regard to social status? Is money important to acquisition of healthcare?

14. Industry Are we headed to a more comprehensive health support system? Does this endanger outcomes and medical power structures? How much is too much integration?

15. Pharmaceutical Industry Life cycle of medication goes from Research, Clinical trials to Regulatory approval Marketing, Prescription and use New indications, side effects and limitations Panacea and safe, or harmful and removed

16. Pharmaceutical Industry Drug as a social phenomena Changing the potential of human kind with psycho-acute drugs Lobbying efforts—patents and control on distribution Who suffers in all of this?

17. Physician relationship to drug companies New rules of ethics in relation to drug representatives Can you take food and pens and be objective and use the best/most effective and cheapest treatment?

18. Examples AIDS drugs and patent infringement Foreign prescriptions and safety OTC drugs Vaccines and older drugs