Dworkin Lecture at Oxford

I have just returned from Ronald Dworkin's Public Lecture entitled "Is Democracy Possible Here?" The lecture addressed themes from Dworkin's latest book of the same title (here).

Dworkin explained that he was motivated to write this book because he is upset with the sorry state of American politics. A state where politicians trade sound bites rather than arguments. Some believe that the division among Democrats and Republicans cannot be breached and thus neither side tries to convince the other. Instead, each side tries to overcome the other side. This thus inspires a "majority rules" conception of democracy that Dworkin finds deeply troubling.

So Dworkin wants to challenge these assumptions for they inspire a vision of politics that is premised on a shallow understanding of democracy and it does not show the value of democracy. For Dworkin, democracy is more of a partnership that it currently is. And thus if America is set on exporting democracy abroad it needs to ask- can we even have it here? Can we achieve it? Dworkin believes we can. That we can find common ground- principles (principles of a certain level of abstraction).

The two principles Dworkin highlights are those same principles of ethical individualism he championed in Sovereign Virtue. Namely, the Principle of Equal Importance and the Principle of Special Responsibility.

So Dworkin asks: how can we improve political argument? His answer is that we need to understand what these abstract principles mean. Indeed, he argued that secondary schools should introduce a mandatory course which would introduce students to political argument.

Dworkin then turned to focus on one particular issue: the role religion should play in political life and government. He outlined two contrasting models: (1) the tolerant religious state (his example was Israel) and (2) the tolerant secular state (his examples were France and to a large extent the UK). The US has had an up and down relationship with these two models. Before WW II the US was (1), then after that war it moved further towards (2)... but now it is heading in the other direction back to (1).

Dworkin then further elaborated on how (1) and (2) are distinct by addressing the 1st Amendment's declaration that government cannot establish any religion. This could be interpreted in one of two ways. The first model (1) sees religion as special, it has central importance. And that is the reason why it is protected in the 1st Amendment. The second model- the tolerant secular state- grounds the protection of religion on a more general right to free exercise. And this right to free exercise applies to other activities- such as the right to abortion, same sex marriage, etc.

Dworkin then introduced a distinction between freedom and liberty. The former is the ability to do what you want unhindered by others. So defined freedom has no value. Liberty, on the other hand, is the freedom that is cherished, that has value. This then set the stage for Dworkin to introduce another distinction- between impersonal justifications and personal justifications. Impersonal justifications that limit freedom as not restrictions of liberty. For example, measures that seek to protect the environment. But personal justifications do threaten liberty.

Dworkin then noted that the most powerful argument for establishing religion are not paternalistic. Rather it is the claim that the majority are entitled to a particular culture. So the important question is- Who gets to shape the culture with which we live? How do we decide to answer this question?

The 2 models give different answers. The culture could be shaped organically... millions of independent decisions about what to buy, what to make, who to talk to, etc. can shape the culture. Or the culture could be shaped through collective political/coercive decisions. Dworkin argued that it has OK to collectively shape the moral culture, but if we hope to take his second principle seriously- the principle of special responsibility- the culture must be shaped organically. And this then leads him to endorse model (2)- the tolerant secular state.

It was a very interesting and engaging lecture. And I was very happy to get the chance to hear a lecture from Dworkin.

Cheers,
Colin

Genetics and Justice Conference

I am organising this two-day conference on "Genetics and Justice" here at Oxford University on July 2nd and 3rd. The final programme of speakers is still being finalised but I expect to post the list of speakers and titles in the next few weeks. The Conference is hosted by Oxford's Centre for the Study of Social Justice, the Department of Politics and International Relations, Oxford’s Programme on Ethics and New Biosciences & the Future of Humanity Institute; and the event is sponsored by the Wellcome Trust.

Those who follow this blog will know this is a topic close to my heart and it should prove to be a unique and interesting event. So far the programme includes scholars from a wide range of disciplines, including medicine, law, sociology, politics and philosophy; and the topics addressed will range from gene therapy for cystic fibrosis and the regulation of PGD, to biobanks and enhancements and sport.

The genetic revolution compels us to re-consider the moral landscape in diverse ways-the chance/choice distinction, the limits and scope of reproductive freedom, the duty to prevent harm, who we define as the "least advantaged", etc. Of course these dilemmas are not all unique to genetics. But what is novel and interesting is how the issue of genetics, and genetic intervention in particular, brings these various concerns together in a vivid fashion.

It is imperative that normative theories keep pace with these scientific advances, that our normative theories evolve in the appropriate fashion as the moral landscape shifts in various ways. This Conference aims to address a wide range of concerns which the genetic revolution has thrust upon us. In order to tackle the moral, legal and social challenges of the genetic revolution there must be interdisciplinary dialogue and exchange so that moral ideals (e.g. inclusion, fairness, liberty) are framed and addressed in ways that give due attention to the diversity of stakes involved in the policies which we implement to mitigate disadvantage, regulate procreative liberty, etc.

Please check back in a few weeks for an update on the final programme.

Cheers,
Colin

Healthcare and the 2008 Presidential Campaign

The 2004 American Presidential campaign focused primarily (if not exclusively) on the issue of winning the war on terror. Could the upcoming election in 2008 actually focus on an issue that (1) has a real significant impact on the life prospects of every single American AND (2) is an issue the government could successfully make a meaning (positive) difference to?

This story in The Boston Globe (registration needed) gives hope that the answer to both questions could be "Yes!". It appears that healthcare, in particular preventative care, is building steam as a priority issue among potential contenders for the White House. Here are a few excerpts from the article:

One presidential candidate wants to give earned days off to federal workers who exercise regularly and do not smoke, while another would press schools to ban junk food. Another candidate plans to reward people who undergo regular physicals and engage in healthy lifestyles with discounts in their health insurance premiums.

Mike Huckabee, former Republican governor from Arkansas, has led the charge for giving financial incentives -- including tax breaks and paid days off -- as rewards for healthy behavior.

....Edwards, the only major party candidate so far to offer a detailed healthcare plan, wants to make health insurance mandatory nationwide, as Massachusetts has done for its residents.

But unlike in previous campaigns when candidates have focused almost entirely on the uninsured, the early presidential candidates are talking about promoting wellness as a way to avoid the high costs of treating cancers, heart disease, and other ailments.

"I think you're going to see a prevention component of virtually every candidate's healthcare reform" plan, said Drew Altman , president of the Kaiser Family Foundation, a healthcare advocacy group. But he said the idea could not take the place of expanding health insurance coverage and controlling costs on a large scale.

"Nobody can pretend we can cover 47 million uninsured people without a huge outlay of money to do it," Altman said.

Despite the disagreement about the finer details of the particular proposals being put forth by Democrats and Republicans, it is truly encouraging to think that serious deliberation and debate of this domestic issue could return to the centre stage of American politics. Current trends in obesity threaten to reduce the life expectancy in the United States (see here). So this is an issue Americans cannot afford to ignore.

Cheers,
Colin

Genetic Justice Paper (posted)

My paper "Genetic Justice Must Track Genetic Complexity" is now posted here on Oxford's "Working Papers Series". That paper is forthcoming in Cambridge Healthcare Quarterly Ethics. Here is the abstract of the paper:

Abstract

What values and principles should inform the regulation of new human genetic technologies (e.g. gene therapy)? To adequately answer this question we need an account of genetic justice. That is, an account of what constitutes a fair distribution of genetic endowments that influence our expected life-time acquisition of natural primary goods (health and vigor, intelligence and imagination). These are goods that every rational person has an interest in (Rawls, 1971). The decisions we now make regarding the regulation of human genetic technologies will determine how quickly and effectively these benefits are brought into existence, as well as who receives these benefits. In this paper I argue that a necessary condition of a defensible account of genetic justice is that it must track genetic complexity. Genetic complexity encompasses phenomena such as polygenetic traits, gene-gene interactions and complex environmental influences. More specifically, I argue that pluralistic prioritarianism is a theoretical position well-suited for tracking genetic complexity.

Cheers,
Colin

Reproduction Ethics (Part II)

As I noted in a previous post, I have been involved in a reading group these past two terms with other CSSJ faculty members.

Today’s reading was Jeffrey Reiman’s excellent article in the latest issue of Philosophy and Public Affairs entitled “Being Fair to Future People: The Non-Identity Problem in the Original Position”.

In my opinion Reiman’s article is an absolute *must read* for those interested in reproduction ethics and the non-identity problem. Reiman’s central argument is that the living have a moral requirement to be fair to future people. This might not struck many as a very interesting or contentious claim. But Reiman’s argument goes much further. According to Reiman, the rights of future people are theirs irrespective of which particular individuals they turn out to be. And thus Reiman offers a potential solution to the long vexed puzzle of the so-called Non-Identity Problem.

You may recall that I expressed some frustration with supposed non-person affecting resolutions of the Non-Identity Problem in this post here. For me, if there is a moral harm then *someone* must have been harmed. Reiman proposes a unique way of developing a person-affecting account of the moral harm done in non-identity scenarios. Invoking Rawls’s original position, Reiman argues that in cases like Preconception Wrongful Disability, the child born from such actions has been harmed (i.e. their rights have been violated), even if it is true that non-existence was the only other option for that particular child. Furthermore, Reiman argues that there is no moral difference between cases of preconception and postconception disability.

Like Reiman, I do not accept the standard move people make when faced with the non-identity problem. That is, to invoke a non-person affecting harm prevention principle. But unlike Reiman I do not think it is true that the harm (or at least the most significant harm) done in such cases is a violation of the rights of future people. Let me offer some thoughts on why I think this is the case.

Our procreative decisions implicate a variety of different people in different ways. Firstly, and most obviously, they implicate the parent(s) him or herself: parents must invest the time and resources needed to raise a child with love and care. These decisions can also implicate our existing children if one has other children: we have to balance the diverse demands of doing right by our existing children with the responsibilities entailed by creating another child. And our decision to have a child will also impact society-at-large, as we have the authority to usher “new membership” cards to our potential offspring. Their membership in the cooperative enterprise does not rest on the assent of the other members of the cooperative venture. Parents have sole discretionary power over who gets into the club of society, as well as how many membership cards are issued.

This interconnectedness of members of a cooperative enterprise means that our procreative decisions raise a number of intrapersonal and interpersonal concerns that must be addressed. Where, among these competing claims and interests, do the claims of “future people” figure? According to Reiman’s argument, if I understand it correctly, the wrongs involved in pre and postconception disability are wrongs (either primarily or perhaps even exclusively) to future people (i.e. the child that is born in these cases). The parents have violated the responsibilities the living have to future people. More specifically, they have violated the responsibility to pursue reasonable efforts to ensure that the level of functioning of future people is within “normal species functioning”.

And what is truly novel about Reiman’s stance is that parents can violate this right even when the contravention of this right is what made the existence of the particular child possible.

So what do I make of this argument? I think the invocation of the device of the original position, for the purpose of developing a moral duty to future people, is misguided. This is not to say that it is implausible or wrong (I’m still mulling that over). But there are many distinct ways of making a particular point. I share Reiman’s intuition that in these disability cases there is a person-affecting principle that accounts for our intuition that the parents are doing wrong. But I do not think it is true that they are wronging (or that the most significant wrong is to) future people. Rather they are harming those who must help shoulder some of the responsibility for mitigating the preventable disadvantage that the parents have created.

So the story I would tell is one of the harms to oneself, one’s existing children, and society-in-general, that can occur in such cases. And my ethical theory (insofar as I have one) would be a hybrid view: one that invokes consequentialist arguments in the case of preconception disability scenarios, and consequentialist and deontological arguments in the case of postconception disability.

The biggest disagreement I have with Reiman’s position is his claim that the wrong involved in the case of preconception disability is analogous to the wrong involved in postconception disability. I believe a hybrid theory could explain why the moral stakes involved in these two cases differ. And I think that is essential in this context.

Lastly, developing the kind of hybrid position I have in mind is attractive because it captures a much broader picture of the moral landscape of procreative ethics. Rather than considering what the consequences of our procreative decisions will be on future people, we will ask what consequences they have for *the living*- for ourselves, for our other children, for the existing disadvantaged who will have to compete for scarce medical provisions, and for the advantaged who will be asked (indeed required) to help mitigate these preventable disadvantages.

So when we start from the “here and now”, we realize that we do not need to invoke the hypothetical device of Rawls’s original position to see the moral wrong involved in such cases. All we need to do is consider how our procreative decisions will impact and implicate the life prospects of those in a society with scarcity and pervasive (unpreventable) disadvantage.

Cheers,
Colin

Donating Eggs for Science

Today's Guardian has this news report that the UK's Human Fertility and Embryology Authority (HFEA) is expected to approve a policy that would permit women to be paid £250 to donate their eggs for scientific research. This issue is a very contentious and difficult issue. I haven't been able to find HFEA's Ethics and Law Committee report on why they have arrived at this decision but perhaps it will be posted on the web later this week when the announcement is made. So I look forward to reading their report.

This issue is a great example of the challenges we face when trying to find a reasonable balance between two laudable aims. On the one hand, we want to minimise the risks of preventable harm that women are exposed to. On the other hand, we want to promote scientific research (like stem cell research) into treatments that could lead to cures for a variety of medical conditions. And if these advances prove to be successful this would mean we could thus reduce a variety of harms and risks of harm. So the question is really one of what would constitute a fair and sensible risk-management policy. Those in favour of permitting voluntary egg donation for science will likely argue that the risk of harm from such a procedure is minimal and the potential benefits (e.g. of stem cell research) could be enormous. Those taking the opposite position will likely argue that the potential risks of harm from egg donation, while minimal, are demonstrable and potentially severe. Given the potential harms are demonstrable, and the scientific gains only speculative, voluntary egg donations for science should not be permitted.

While those critical of permitting voluntary egg donations for science might highlight the risks of egg donation, it is important to bear in mind that we permit women to voluntarily expose themselves to these same risks when they undergo IVF. So women can take these risks for something that has no direct medical benefit to themselves. Furthermore, we permit women to expose themselves to these risks even when the potential non-medical benefits (i.e. having a child they are biologically related to) are not guaranteed. The success rate of artifical reproductive technologies varies depending on the age of the women, the cause of infertility, and the number of embryos transferred. According to this report from the U.S, the national average success rate of artificial reproductive technologies is 28%. So it is important to bear this mind when considering permitting voluntary egg donations for science. If we permit women to expose themselves to these same risks for the chance (not certainty) to have children they are biologically related to, should we not permit them to voluntarily expose themselves to these same risks for the chance to benefit medical science? Furthermore, we permit healthy volunteers to consent to participating in clinical trials, trials that expose them to some risks of harm. So I think it is natural to ask: should we not permit women, who would be informed of the risks of egg donation, to decide if they are willing to tolerate such risks for the chance to benefit medical science?

I think the really central issue comes down to the likelihood and severity of the potential risks and the likelihood and magnitude of the potential benefits such donations could make to science. There is uncertainty and disagreement about both of these issues. The lower the risk of the harm from egg donation, and the greater the likelihood that such donations will reap tangible scientific benefits, the greater the case for permitting voluntary egg donations for science.

One interesting component of the proposed policy that I think should relieve some of the concerns of its critics is that potential donors must demonstrate they are acting for altruistic reasons. For example, that they wish to help scientists develop a treatment for a condition that inflicts a close relative. If this policy can actually be implemented in a way that permits regulators to distinguish between those who wish to donate for genuine altruistic reasons vs those who are doing so primarily for the money, then I think this further tips things in favour of the policy. So does the fact that the amount of money involved here is modest. It would be different if the money being offered was thousands of pounds. So these features of the policy reduce the likelihood that it will result in the exploitation of women.

The BBC has an interesting video report on these issues here (on the right hand side). And News@Nature had a special report on these issues back in August. You can download that report here.

Cheers,
Colin

Multigene Prognostic Test

The latest issue of Science has this interesting News of the Week piece by Jennifer Couzin concerning the FDA's decision (last week) to issue its first-ever approval of a multigene prognostic test. The test is called MammaPrint and is developed by an Amsterdam-based company. The test is currently available in Europe and it aims to predict a breast cancer's risk of recurrence.

As Couzin notes, there are concerns about the oversight of gene-based tests such as MammaPrint. In particular, there are concerns about accuracy and transparency. Here is an excerpt from the article that illustrates the challenge of striking a balance between the different concerns in this context:

But now FDA wants to extend its oversight to many more gene-based tests. In September, the agency released a draft document suggesting that many prognostic tests should be regulated as medical devices, which would vastly expand the agency's oversight of them. This policy would cover many candidate tests, including, possibly, a method for identifying the primary source of metastatic cancer and a blood test to determine whether a transplanted heart is being rejected. "We had concerns" about this class of products, said Steven Gutman, FDA's director of the Office of In Vitro Diagnostic Device Evaluation and Safety, at last week's meeting in Gaithersburg, Maryland. Accuracy is one concern, he says, as is a "lack of transparency" about how the tests are performed. FDA is accepting comments until 5 March.

At FDA's meeting, many companies and some patient advocacy groups argued against FDA's proposed policy. They suggested that requesting more extensive clinical trials would impose a financial burden that diagnostics outfits can't afford and possibly add a decade's delay. "We can't wait that long," says Charles Perou, a geneticist at the University of North Carolina, Chapel Hill, who is trying to commercialize a breast cancer prognostic test but did not attend the meeting.

Two of the breast cancer tests that are farthest along, MammaPrint and Oncotype DX, have settled on a middle ground: The companies are marketing their tests to doctors on the basis of retrospective studies of stored tissue while long-term clinical trials of breast cancer patients run simultaneously. MammaPrint uses a 70-gene signature to stratify women with breast cancer that hasn't spread (typically one of the groups that may avoid chemotherapy) into "low-risk" or "high-risk" categories. Oncotype DX relies on a 21-gene analysis to help inform clinicians whether patients with localized, estrogen-receptor-positive cancer are at risk of relapse. And although CEO Randy Scott of Genomic Health, the Redwood City, California, company that makes Oncotype DX, believes that these tests should be developed as "you would develop a drug," he does not think they should be regulated as such. "We're not injecting anything into the body," he says.

But some physicians see significant risks. "If I withhold lifesaving therapy from a patient because of a bad test, that's every bit as bad as if I gave her a bad drug," says Daniel Hayes, a breast cancer specialist at the University of Michigan, Ann Arbor, who helps run an Oncotype DX trial.

A further illustration of the complex challenges raised by the genetic revolution.

Cheers,
Colin

Brain Cancer Research

Forbes has an interesting story about the discovery of a gene (called Olig2) that triggers the growth of stem cells during early brain development and is also important to the growth of deadly adult brain tumors. Here is a brief excerpt:

Olig2 "is specific to growth in the brain, and if you are able to target the activity of this gene, you might have something that would specifically work on cells in the brain but not have the adverse side effects in the rest of the body," Rowitch said.

In experiments on mice, his team found that blocking the function of the protein almost completely stopped the gliomas from forming. That means that drugs that targeted Olig2 might kill tumor cells without affecting healthy brain tissue, the researchers say.

...."The charm of Olig2 is that it is confined to the brain," Stiles said. "Although you need Olig2 to develop a brain, and perhaps you need Olig2 to repair certain lesions in the brain, you can go for quite some period of time without Olig2 once the brain has been developed."

Targeting Olig2 as a treatment for brain cancer is still a decade away, Rowitch said. "But I am hoping that this work will lead to an era of targeted therapy for brain cancer."

The article published in Neuron is here.

Cheers,
Colin

Child Poverty in UK

This story in today's Guardian reports on the UK's poor rating in the recent Unicef "report card" on the wellbeing of children and adolescents. Here is an excerpt from the story:

Children growing up in the United Kingdom suffer greater deprivation, worse relationships with their parents and are exposed to more risks from alcohol, drugs and unsafe sex than those in any other wealthy country in the world, according to a study from the United Nations.

The UK is bottom of the league of 21 economically advanced countries according to a "report card"' put together by Unicef on the wellbeing of children and adolescents, trailing the United States which comes second to last.

UPDATE: CNN has the story as well here. That link provides a full list of the rankings, which I reproduce below.

UNICEF RANKING IN FULL
1. Netherlands
2. Sweden
3. Denmark
4. Finland
5. Spain
6. Switzerland
7. Norway
8. Italy
9. Ireland
10. Belgium
11. Germany
12 = Canada
12 = Greece
14. Poland
15. Czech Republic
16. France
17. Portugal
18. Austria
19. Hungary
20. U.S.
21 UK

Cheers,
Colin

Study on Adoptive Parents

This is an interesting news report about a recent study which suggests that adoptive parents invest more time and financial resources in their children than biological parents. The study that is the focus of the report is here.

Cheers,
Colin

Rett Syndrome Study

Approximately 1 in 10 000 - 15 000 girls are affected by Rett syndrome. The National Institute of Neurological Disorders and Stroke has useful info on Rett syndrome here. Here is a small excerpt from that site:

Rett syndrome is a childhood neurodevelopmental disorder characterized by normal early development followed by loss of purposeful use of the hands, distinctive hand movements, slowed brain and head growth, gait abnormalities, seizures, and mental retardation. It affects females almost exclusively.

....The course of Rett syndrome, including the age of onset and the severity of symptoms, varies from child to child. Before the symptoms begin, however, the child appears to grow and develop normally. Then, gradually, mental and physical symptoms appear. Hypotonia (loss of muscle tone) is usually the first symptom. As the syndrome progresses, the child loses purposeful use of her hands and the ability to speak. Other early symptoms may include problems crawling or walking and diminished eye contact. The loss of functional use of the hands is followed by compulsive hand movements such as wringing and washing. The onset of this period of regression is sometimes sudden.

More information about Rett syndrome can also be found on the International Rett Syndrome Association webpage here.

The latest issue of Science brings some encouraging news to those who suffer from Rett syndrome. This news report notes that researchers have been able to reverse some of the dramatic neurological problems of Rett syndrome in an experimental mouse model. Here is a snippet from the news piece:

Some of the dramatic neurological problems of Rett syndrome can be reversed in an experimental mouse model, researchers have found. Although the work does not have direct therapeutic applications, scientists studying the devastating genetic disorder hail the findings as a sign that treatments are at least possible in principle. "This is very exciting," says Huda Zoghbi, a geneticist at Baylor College of Medicine in Houston, Texas. "It gives us researchers and the families and patients hope that, as we uncover [biochemical] pathways that could be safely manipulated, we can recover some function in these girls."

....Mutations in a gene called MECP2 are to blame....

Jacky Guy and Adrian Bird of the University of Edinburgh, U.K., and colleagues created mice with a genetic roadblock--a string of DNA--inserted into Mecp2 (the mouse version of the human gene) that prevented cells from reading the gene to make the protein it encodes. Female mice with the blocked Mecp2 developed normally for 4 to 12 months before showing Rett-like symptoms, including impaired mobility, an abnormal gait, tremors, and breathing difficulties.

Then the researchers turned Mecp2 back on, exploiting another gene they'd bestowed on the mice. This gene encoded a hybrid protein: a DNA-splicing enzyme fused to an estrogen receptor. The enzyme can recognize and remove the roadblock in Mecp2, but the attached estrogen receptor prevented it from entering the cell nucleus. By injecting the mice with tamoxifen, a drug that binds estrogen receptors, the researchers sent the hybrid protein scuttling into the nucleus to snip out the roadblock and restore Mecp2.

After the mice had received five weekly tamoxifen injections, the Rett-like symptoms all but disappeared. A few of the rodents continued to walk with their hindlimbs abnormally far apart, but otherwise they were hard to distinguish from their genetically normal relatives. It was a pleasant surprise, because researchers had feared that the developmental loss of Mecp2 led to missing or permanently disabled neural connections. "The general perception is that once the brain has missed out big time on some ingredient of normal development, it's never going to be able to recover," Bird says. "We thought maybe we'd get amelioration of the symptoms, but we didn't anticipate that things would be reversed on the scale that we found."

The actual report can be downloaded here (subscription needed). Here is the abstract:

Reversal of Neurological Defects in a Mouse Model of Rett Syndrome
By Jacky Guy, Jian Gan, Jim Selfridge, Stuart Cobb, Adrian Bird

Abstract: Rett syndrome is an autism spectrum disorder caused by mosaic expression of mutant copies of the X-linked MECP2 gene in neurons. Neuronal death is absent, suggesting that this is not a neurodegenerative disorder. An important question for future therapeutic approaches to this and related disorders concerns phenotypic reversibility. Can viable but defective neurons be repaired, or is the damage done during development without normal MeCP2 irrevocable? Using a mouse model, we demonstrate robust phenotypic reversal, as activation of MeCP2 expression leads to striking loss of advanced neurological symptoms in both immature and mature adult animals.

Cheers,
Colin

The Importance of the "Big Picture" Perspective

There is a very good article on the importance of the "big picture" perspective in healthcare in the latest issue of JAMA. It's a Commentary piece by Steven Woolf entitled "Potential Health and Economic Consequences of Misplaced Priorities". You can download it here (subscription needed). Here is a sample:

To maximize the health of its citizens, society should pursue interventions in proportion to the ability of those interventions to improve outcomes. All else being equal, a strategy that is more effective than its alternative should receive more, not less, attention. Doing otherwise can compromise the health of patients. For example, if intervention A is 10 times more effective than intervention B in reducing mortality, performing more of B than A will allow more deaths to occur. Just as errors of omission cause harm, inattention to how priorities are balanced can indirectly claim lives, contribute to disease, and generate costs that would not occur if priorities were in greater harmony with potential gains.

The "silo" mentality that pervades so much of clinical practice and policy in the United States often finds decision makers focusing their attention and resources on a specific patient or disease—any one is a worthy cause—without stepping back to examine the balance of their efforts. Most practitioners and policy makers rarely pause to consider whether more rational priorities would offer better outcomes for their patients.

Lacking this "big-picture" perspective, many choices in clinical practice, policy, and research end up concentrating resources on interventions that do less for health while shortchanging alternatives that would save more lives. Reordering priorities to maximize health benefits is essential not only on moral grounds—to lessen disease burden on the public—but also as a necessary countermeasure to increasing health care costs. To illustrate the importance of reordering priorities, this Commentary presents examples from 4 areas of practice and policy: choosing effective services, delivering care, preventing disease, and fostering social change.

Cheers,
Colin

Snow in Oxford

This was the view out my window this morning. It looks more like Canada than the UK! I suspect the snow will be gone by tomorrow. This is the second day it has snowed here this winter. The kids love the snow, and I must admit that seeing it this morning made me feel homesick.

While many schools in Oxford were closed today due to weather, unfortunately the primary school for my children was open. So our snowball fight will have to wait till another day!

Cheers,
Colin

Main Menu (Feb. 2007)

Here are a sample of some of the recent posts on offer at "In Search of Enlightenment".

#1. Sabbatical: What I am doing this year? Find out here. And some related updates here, here and here.

#2. Is Marx Still Relevant today?: Find out my thoughts here.

#3. Palgrave Book: A project that has been a long time in the works and should be out in print within the next few months. See here.

Cheers,
Colin