October 21, 2004

Half the modern drugs could well be thrown out the window

I blogged about the problem of weighing drug risks and benefits on the
CNEhealth.org Blog in the light of the Vioxx and Prozac debates. How can we tell when the risks outweigh the benefits, when trials are too expensive, biased and sometimes unethical and benefits not necessarily anything that can be quantitively measured?

The key point is that the current drug testing and regulation system works best on new drugs that cure an operationally well-defined condition. There is no old drug to compare with, requiring people to do inter-drug tests rather than drug-placebo tests (since it would be unethical to do that if there is a cure). Also, there are not yet vested interests promoting one drug before the other. The condition needs to be well-defined and measurable, so that one can tell if the drug works objectively. Did the patients survive, did the fever decrease?

But as medicine advances we get more and more drugs intended to promote health - a state of high life quality - rather than just remove a clearly negative condition. How do we measure whether they achieve that, to what extent and whether this extent is great enough to outweigh the risks?

These questions are hardly new, and have been discussed in the medical profession endlessly. But as health policy grows more and more political, it means that these questions move into the political sphere. In a few years we will vote about our definitions of health if we are lucky. If we are unlucky we will have a commission (which may or may not include the medical profession and certainly will include some savings-hungry politicians) deciding for us with little public input but great effect on medical availability.

The best way of dealing with the qualitative aspects of health is to leave as much open for informed individual choice. As long as availability of medicines is centrally controlled according to the seemingly objective numbers of a few trials we will get more optimization of public health in the sense of public health expenditures and politically convenient risk aversion than improving the health of individuals. It is the classic information problem: the patients and their local doctors know best how their health works, but the central planner only knows aggregate numbers. If patient/doctor teams can gain health information easily and flexibly to make informed choices, and if the local information about side-effects and experiences can be aggregated efficiently (e.g. by local reports through the net into data mining systems) then the importance of large-scale centralized trials could be decreased. But it will take a strong doctor-patient collaboration, some advances in e-medicine and a deliberate push towards a more voluntaristic pharmaceutical regulation system and health insurance system.

Half the modern drugs could well be thrown out the window except that the birds might eat them.
Martin H. Fischer, Fischerisms

Fischer's quote reflects a common sceptical view of medicine: we know a lot of the pills we take are not that powerful compared to placebos. At the same time we dearly hope they are as powerful as the alchemical elixir of life. And as free from side-effects as the elixir was reputed to be. We manage to be both cynical about the efficacy and safety of drugs, yet take them eagerly. Which probably goes to show that most people are not very committed cynics.

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