1. Ethical Concerns in the Practice of Medicine Otis W. Brawley, MD, MACP, FASCO, FACE Chief Medical and Scientific Officer American Cancer Society Professor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University Atlanta, Georgia, USA

2. Disclosures Employment: – American Cancer Society – Emory University – Turner Broadcasting (CNN) Consulting – National Institutes of Health – Centers for Disease Control – Department of Defense I do not accept money from drug and device manufacturers

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4. Medical ethics is a system of moral principles that apply values and judgments to the practice of medicine. 4

5. Principles of Ethics Beneficence Non-maleficence Respect for Autonomy Justice 5

6. Healthcare An issue that must be approached ethically, logically and rationally We must realize the truth: – What we know. – What we do not know. – What we believe. 6

7. Overview The U.S. health economy. Observations about our attitude toward medicine. Lessons from the history of medicine. The future increased effort to prevent chronic disease.

8. The Cost of Healthcare 8

9. U.S. Health Care Spending In 2011, the U.S. spent $2.7 TRILLION on Health Care 9

10. U.S. Health Care Spending How Big is a Trillion? 1 million secondsLast week 1 billion secondsRichard Nixon’s Resignation 1 trillion seconds30,000 BCE 10

11. Spending in Context 2011 *Excludes alcoholic beverages ($150 billion) and tobacco products ($92 billion) Source:Bureau of Economic Analysis; National Bureau of Statistics of China, MGI analysis $2.7 trillion $1.1 trillion $1.4 trillion Gross Domestic Product 11

12. Gross Domestic Product by Country, 2011 Thrillion Dollars, at Official Exchange Rate United States 14.45 China 5.74 Japan 5.46 Germany 3.28 France 2.56 Brazil 2.09 CIA Fact Book, 2012 12

13. Healthcare in Three Countries (2010) CanadaSwitzerland U.S. Infant Mortality5.04 4.53 6.22 per 1000 live births White Male Life Exp78.0 79.7 76.8 Y ears Per Capita Costs4445 5270 8233 US Dollars Proportion of GDP11.4% 11.4% 17.9% 13

14. Disparities in Health Some consume too much – (Unnecessary care given) Some consume too little – (Necessary care not given) We could decrease the waste and improve overall health!!!!

15. Disparities in Health Of all the forms of inequality, injustice in health care is the most shocking and inhumane ML King, Jr. Presentation at: The Second National Convention of the Medical Committee for Human Rights; March 25, 1966; Chicago, IL. 15

16. Is there value in American healthcare? Bringing rationality to American healthcare Orthodox application of the science “Rationality” not “Rationing”

17. The American Healthcare System Overconsumption of Healthcare The Greedy Feeding the Gluttonous A Subtle form of Corruption 17

18. Themes Greed Ignorance Apathy 18

19. Themes People – Who should know better, but do not – Who do not appreciate scientific findings nor the scientific method – Who discourage those who question 19

20. “A professional is someone who puts the interests of his patients above his own.” Hal Sox, MD, MACP 20

21. The Doctor Culture Respect for tradition (Unwilling to evolve or change). Intolerant of those who question. Hubris

22. “It is difficult to get a man to understand something, when his salary depends on his not understanding it.” Upton Sinclair 22

23. The Patient Culture The Situation. – Demands irrational patterns of consumption – Unreasonable expectations – Advocacy often worsens healthcare by stressing the wrong things

24. The Patient Culture For true transforming of healthcare the public needs to believe there is a crisis and it affects them. – Personal responsibility – Solid financial incentives (skin in the game)

25. The American Healthcare System Inefficient!!! We often do not follow the science We often use treatments and interventions that are lucrative to the providers but not proven effective. We often ignore and fail to use simple, inexpensive, and effective interventions.

26. Culprits in Inefficiency Doctors and Nurses Patients (Consumers) Hospital Administrators Lawyers and Politicians Marketers and Salesmen (Drug and Device Companies)

27. Clinical Lessons Learned Late Chest X-ray screening for lung cancer Urine screening for neuroblastoma Cryotherapy for prostate cancer

28. Clinical Lessons Learned Late Lidocaine after MI Hyper-vitaminosis (Vit E, Beta Carotene, Selenium) Rofecoxib and Celecoxib for arthritic pain – (Vioxx and Celebrex) Rosiglitazone (Avandia) for diabetes

29. Clinical Lessons Learned Late Postmenopausal Hormone replacement therapy Halsted mastectomy Adjuvant bone marrow transplant for breast cancer Erythropoetin for anemia

30. Clinical Lessons Learned Late Overused Interventions Hysterectomy Caesarian section Carotid endarterectomy Coronary Artery Bypass Grafting Tonsillectomy Tympanostomy

31. Our History of Not Respecting the Science The Halsted Mastectomy Bone Marrow Transplant in Breast Cancer Erythropoetin to stimulate blood production in cancer patients Mass Prostate Cancer Screening Lung Cancer Screening

32. Our History of Not Respecting the Science The Halsted Mastectomy – Defined by Halsted in 1896 – Appropriate treatment in the early 20 th century (tumors large at diagnosis) – Doctors who questioned it in the 1940’s were disciplined – Shown obsolete in 1970’s through studies of Fisher and Veronesi

33. Our History of Not Respecting the Science Bone Marrow Transplant in Breast Cancer Began in 1980’s due to theory that more chemotherapy was better Women sued insurances to pay for it Laws passed forcing insurances to pay for it Clinical trials impeded 1999, three studies show it net harmful and 200 transplant centers close in U.S.

34. Our History of Not Respecting the Science Erythropoetin to stimulate blood production in cancer patients Approved without full testing during the AIDS epidemic as an alternative to blood transfusion Advertising to push the envelope in terms of FDA approval Suppression of studies to show it is a stimulant of cancer cell growth

35. Our History of Not Respecting the Science Mass Prostate Cancer Screening Pushed based on early detection principles from 1991 onward Professional organizations warn of proven harms and unproven benefit Studies published 2009 to present show small benefit if any.

36. American Urological Association* Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical. Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion. * Taken from the AUA PSA Best Practice Statement 2009 and markedly different from statements made in press conferences

38. Our History of Not Respecting the Science Lung Cancer Screening Pushed based on early detection principles before good trials showed it saves lives Professional organizations warn of proven harms and suggest informed decision making Some hospitals push it hard and even offer at low cost without any mention of harm!

39. Offers Low Dose Spiral CT of the Lung to those at risk for lung cancer. ($325 cash). “At risk for lung cancer,” according to St Joe’s, includes 40 year old non-smoking women who have lived in an urban area for more than ten years. The business plan relies on insurance to pay for the follow-up testing of the 25% or more abnormal screens. 39

40. Rational vs. Irrational Medicine Rofecoxib (Vioxx) vs. Naproxen Once a day vs. twice a day $90 per month vs. $12 per month 40

41. Rational vs. Irrational Medicine Omeprazole (Prilosec) 41

42. Rational vs. Irrational Medicine Omeprazole (Prilosec) vs. Esomeprazole (Nexium) 25 cents per day vs. six dollar per day Eight dollars per month vs. 180 dollars per month 42

43. True Healthcare Reform A transformation in how we view medicine: -Less overindulgence -Less focus on treatment -Greater focus on prevention 43

44. True Healthcare Reform The use of “Evidence Based Care and Prevention” That is:  The rational use of medicine  Not the rationing of medicine Comparative Effectiveness Research 44

45. U.S. Smoking Prevalence by Gender 1955-2010

46. US Continues to Lead the World in Obesity Rates OECD Obesity Update 2012

47. A Tsunami of Chronic Disease – Diabetes – Cardiovascular Disease – Orthopedic Disease – Cancer

48. A Tsunami of Chronic Disease Will surpass tobacco as leading cause of cancer Think of the number of people we could save from a cancer death if we did what we know we should do 48

49. An Ethical Issue We need to focus on the prevention of disease We have been too treatment centered.

50. True Healthcare Reform (An Efficient, Value Driven Health System) Rational use of healthcare is necessary for the future of the U.S. economy (an issue of U.S. security) There is a healthcare fiscal cliff!!! It is possible to decrease costs and improve healthcare by using science to guide our policies 50

51. Otis W. Brawley, MD, MACP, FASCO, FACE Chief Medical and Scientific Officer American Cancer Society Professor of Hematology, Medical Oncology, Medicine and Epidemiology Emory University 51