Dr Jim Duthie
Last week I had the opportunity to attend a small breakfast meeting where the speaker was Dr Catherine Mohr. Dr Mohr is an extraordinary individual (see http://www.catherinemohr.com/), originally trained in Medical Engineering at MIT, then going on to study Medicine at Stanford. She has a knack not only for problem-solving, but also problem-identifying, and it was fascinating to hear some of her insights. In her role as Vice President of Medical Research at Intuitive Surgical (makers of the da Vinci Surgical Robot) Dr Mohr asks herself questions such as: ‘Can we use a robot to operate on the retina?’ and ‘Is preparing for a time when fluorescent biological markers will tag tumour cells in order for the cells to be individually excised by a surgeon, leaving healthy cells undamaged?’
As a surgeon with a specific interest in technology, I was captivated and would recommend taking the opportunity to hear Dr Mohr speak should you ever get the chance. In the hours following the talk, however, I was struck with a sense of conflict in my role as a clinician. ‘Conflict’ is the operative word, as one definition of conflict is: ‘Disagreement over the allocation of a limited resource.’ At the level of personal relationships, conflict can stem from the allocation of one partner’s time to the other, and at the international level it has arisen from the allocation of natural resources such as land and oil. After Dr Mohr’s talk I identified a conflict over the finite health resources we have as a global community. It is clear that the advances outlined in Dr Mohr’s talk will be limited for the foreseeable future to the infinitesimal fraction of the world’s population that has the financial power to access them. I am convinced that we need innovation in medicine. I have no illusions about how crude medical, and particularly surgical practice, was before the exponential growth in technology over the past century. I admire the work of Dr Mohr and her colleagues without reservation, and believe that they are essentially working in a moral vacuum in terms of responsibility towards the global health community. Their job is to advance medical treatment within the bounds of a corporation’s legal and ethical boundaries, not to ask philosophical questions over unequal allocation of health resources.
That role is filled by the clinician. We are in a unique position, balancing responsibilities not only to the patient in front of us, but to patients at large. Most medical fraternities recognise Justice, along with Autonomy, Beneficence, and Non-Maleficence as ethical rules. Justice is why we do not prescribe unnecessary antibiotics; there may be negligible harm to the patient in question, but potential for harm to the wider community from antibiotic resistance. All patients matter, not just our own. Justice is the principle of striving for equitable, if not equal, access to medical care. As doctors with a duty to Justice, it is up to us to ask our communities whether we value air quality over a procedure that benefits a small handful of individuals. Or a refinement in an instrument that yields a marginal benefit in outcomes, over a cheaper, smarter water filter design that benefits entire continents. Amoral corporations exist solely to benefit their shareholders; as doctors we need to continuously ask ourselves whether we exist to generate income, make people better, or attempt a sustainable compromise between the two ideas.
Pure Free Market theory would dictate that one would follow the other; that provision of the best possible care would result in the highest income. In practice, however, the most conspicuous Western free-market medical system, in the USA, has resulted in perhaps the highest rates of over-diagnosis and over-treatment of disease.1 Clearly, practicing medicine is different to selling hamburgers; on the one hand an over-enthusiasm for technology that benefits the minority diverts resources from larger groups of patients with higher morbidity, and on the other hand risks unnecessary morbidity from over-treatment to the group that can afford it.
The da Vinci surgical robot (of which I am a user) has been demonstrated to save money on prostate cancer surgery due to more rapid recovery and fewer complications in developed countries.2 I acknowledge that, in time, some technologies will result in greater efficiency for all, but does anyone consider that this kind of cutting-edge equipment (introduced 14 years ago) will be accessible in developing countries in the next 5 years? 15 years? When simple sterilisation equipment is currently out of the reach of many communities, I suspect not.
The questions that are asked of us as doctors are difficult. Do we have the courage and character to tell a hospital board to spend resources on public health initiatives over new technology or expensive drugs that provide a small benefit to a very few? Can we sacrifice personal and corporate glory (and income) for anonymous but large-scale good? Do we take Justice seriously enough to consider our patients to include those outside of our practice, our cities, our national borders? I laud Dr Mohr for her work. She is achieving extraordinary things in an environment where the question is: ‘Can we?’ For doctors, with the responsibility to represent and advocate for the sick at large, our question needs to be: ‘Should we?’
In the interests of full disclosure, Jim was a pivotal advocate in the acquisition of a new da Vinci Surgical Robot at his hospital.
1. For an overview see http://well.blogs.nytimes.com/2012/08/27/overtreatment-is-taking-a-harmful-toll/?_php=true&_type=blogs&_r=0
2. See Dr Mohr’s piece on this at http://freakonomics.com/2010/07/20/is-robotic-surgery-cheaper/