Firstly, where does the funding come from? It comes from peoples’ taxes. Why not give the taxes back and let people voluntarily donate to medical research? Surely, if everyone is in agreement that the sorts of projects currently funded are so vital they would voluntarily hand over their hard earned cash. If we accept the arguments of vocal researchers, it is a lay down misère that people will continue to support medical research; so surely there’s no worries there? What if for some reason people don’t want to donate their money voluntarily?  Well that should tell us something about how important people really think this expenditure is. How should capital be most effectively distributed? Do we have to re-invent the economic wheel about resource allocation? What is the benefit to an individual of investing in research that has a far off benefit that might not ever be utilized by that person. For example donating to a project that might contribute a drop in the ocean to finding a cure for cancer has to be weighed against other expenditure the person might make; such as updating their home IT infrastructure which might bring the more immediate benefit of increased work efficiency. Or even, dare I say it, a trip to the football with the family.

There is no ultimate answer as to what is the best way to allocate resources; the question is answered by the billions of interactions and decisions that individuals collectively make in their lives. Maybe people value short term gratification more than the long term benefits that research may  bring. We don’t forcible make someone undertake a course of action in order to further someone else’s health. That would immediately be recognized as contravening basic medical ethics. But can we trust “ordinary” people to understand how important  research is. They might be too “stoopid” to effectively allocate their resources. The “elite” need to make those decisions for the ordinary folk. Unfortunately that is what is at the very core of arguments that the Government must fund research.

The second reason that it would potentially be a good thing to slash Government funding is that many of the projects that are funded are complete rubbish. But how do we decide which projects are worthy and which are not. What is needed is some market discipline. People will tend to donate to projects that are seen to be more relevant. How will people know which are more relevant when they don’t have expertise in the area? It will happen the way resources are always allocated. People will develop confidence and trust in certain institutions and will be likely to follow their recommendations.

The current system is probably the worst way to effectively allocate scarce resources. That is, having “experts” undertake the sometimes farcical exercise of determining what is a “better” project. This bureaucratic “Yes Minister” approach flaunts everything we know about the human conditions and decision making. We accept that judges, economists and politicians make decisions on information presented to them based on their pre-conceived ideas. Committee members deciding on which grants to fund are no different. Researchers and clinicians can spend decades debating the effect of a single drug. Yet there are impossible combinations of indices to consider when judging the worthiness of research grants.

While invoking the concept of Yes-Ministeresque, strangulating bureaucracy, it would be naïve to think that which grants were funded was not a function of who the committee was stacked with. Like every industry, there is certainly an in-crowd. With peoples’ careers, reputations and livelihoods on the line depending on funding decisions, it would be somewhat unbelievable to think that the right connections are not important. This may play out at either a conscious or subconscious level, but we know that this is an inevitable part of such a system. Ideology plays an important part too. Should we, for example, be funding more or less indigenous health projects. I study (amongst other things) the effects of illicit drug use. I accept however, that many people think less money should be spent on that and more on cancer. The question entails fundamental value judgments about where peoples’ individual responsibility should be in respect of things that they can and can’t change. Let people vote with their hard earned. Otherwise we merely have an entrenched, narrow, ideologically based system which is immune from community expectations. If you drew a distribution of the ideology and political persuasion of health academics and that of the general population it would probably not be the same.

The current, insulated in-crowd-oriented system of medical research funding has incredibly inefficient practices entrenched within it. Every other field of human endeavor has realized that such bureaucratic systems actually cause a decrease in productivity. Maybe it’s time for a clean out of the system.

(This is a guest post from Michael Keane, libertarian and health care professional)

When I see such a mismatch, I begin to wonder why this is so. Donating your organs is such an altruistic commitment that gives life to another.  Obviously, there is a gap between what people need (ie. live saving organs) vs what people are willing to give. There are a number of ways to reduce this gap:

1. More education: this entails public service announcements pleading with us to donate our kidneys, hearts, lungs and other organs. The onus is still on the individual to voluntarily “opt-in” to the donation system.
2. Opt-out: Make everyone donate by default unless you specifically “opt-out”. This has a default position of “somebody else has a right to your organs after you die”. We, as a default, should have a natural right over our bodies after death just like we have rights of our property after death.
3. Allow Organ Trading: For those that can afford it, people should be able to buy organs in an open, but regulated, market. For those that cannot afford it can access the current donation system, get subsidized by the government or receive charity from non-profit organisations. More on this below.

Organ Trading as Public Policy

My Liberal Democrat colleague, Phillip Lillingston, and myself (I must say that Phillip is the real champion and original author) are constructing an organ trading public policy for the Liberal Democrats. Below is a discussion piece on the subject.

Introduction

The Victorian Health Minister is currently arranging a parliamentary committee to examine the possibility of making post mortem organ donations default positive instead of default negative. This is due to the fact that terminally ill people suffering organ failure die due to the lack of available organs.

Currently if an Australian is terminally ill and needing an organ transplant all he can do is go on a list unfortunately longer than that of available organs. That is unless someone close to him may like him enough that they would be prepared to voluntarily donate an organ even though it will have a small effect on the donor’s long term health.

If an otherwise dying person is lucky enough to find such a friend willing to donate she or he still has a 30% chance of disappointment due to the fact that all potential donors and their recipients are not tissue or blood group compatible.

Only 309 Australians donated organs in 2010 while there were 1700 people on the official waiting lists at any one time. A post mortem donation of organs from a single body often goes to as many as four people, so even though people die every year due to inability to receive donated organs the figure is not as high as the above statistic. initially implies.

No hard statistics are readily available but Victorian Health Minister David Davis has been quoted in the Herald Sun ‘Auto Organ Donors’ 14^th Feb 2011 as saying that changing Victoria’s consent laws on organ donation will save hundreds of lives. . This extrapolates into nearly one thousand lives across Australia. This does not mean that the honourable minister is necessarily correct with regards to the results of legislative change but only that there are many Australians dying from organ failure.

Having a universal default position of organ donation as a remedy still entails many problems.

The donation has to be confirmed by relatives of the deceased, and apart from religious considerations, many people in a state of trauma on the death of a loved one find it very difficult to agree to have that loved one immediately cut up into pieces.

As a solution to this problem why not simply introduce a law declaring the absolute proprietary right of a person to his or her own body? People would have the right to voluntarily donate or sell their organs, blood and other body tissues, to be delivered pre or post mortem in a regulated but open market.

What are the advantages of an organ market?

• There would be a greater incentive for people of all ages to agree to donate upon death if they knew the post mortem payment would go to their estate and thus to the loved ones to whom they had willed their assets. A death of a loved one, primarily the families bread winner, is particularly devastating. The option for the surviving family to receive some level of financial support from the deceased organs will provide some financial assistance in their time of need.
• Live donations (such as for kidneys) would increase and thus reduce fatalities of those suffering organ failure.
• One can’t predict what the eventual market price for a  an organ but would be but it is reasonable to believe that  if it is going to save a life of a person of a first world country it may be up to $100,000. If even half of that, it is still a substantial amount of money for an impecunious person who may well find the possible loss of five years of life expectancy a fair exchange.
• A voluntary donor who previously was thwarted due to blood or tissue incompatibility could now simply sell his organ to the highest compatible bidder and then with the proceeds purchase a compatible organ for his friend.
• Reduces the unsavoury aspects of the human organ black market.

Responses to commonly asked questions about an organ market

It’s exploiting poor people.

• It’s OK for poor people to voluntarily donate an organ now. Why should it suddenly become a crime if the poor now actually get paid for their services?
• Isn’t it for poor people themselves to decide whether or not they wish to be “exploited”? Are you saying that people in the lower socio economic ranks are not only poor but also uninformed and thus need politicians to say what contractual arrangements they may or may not enter into? Who are politicians to decide that people poorer than themselves can’t find their own ways to make some substantial income?
• If a building tradesman should decide to head up to Queensland to make some money by cashing in on the high prices now paid to carpenters to rebuild following the cyclone damage, is his “exploitation” of Queenslanders’ current problems a crime?
• If in a hypothetical situation a wealthy person with a rare blood group was needing an urgent organ transplant and the number of potential and immediately available donors had decreased to just one, and the price offered was $1,000,000, who then would actually be exploiting whom? If then it was the potential recipient, do we still make the trade illegal so as to prevent the wealthy person from being exploited?

It decreases the number of voluntary donations.

• Statistics in Iran, where it is legal, don’t reveal that.[Reason Magazine, ‘Kidneys for Sale, June 2008]
• Those who only look at organ donation as a voluntary action might still be tempted to donate if they decided to donate to only those who could not otherwise afford to buy one.
• Alternatively those who might feel repulsed by accepting money for such an action could donate their payment to their favourite charity.

Donors will very often suffer health problems later in life due to the organs they have given away.

• The only difference between the current legislation and the proposed is that money is involved. It is hard to imagine how the addition of money can make things worse for the health of the donor.
• Many jobs have ‘danger money’ allowances attached to the employee’s remuneration, either implied or overt. The worker gets paid extra to compensate for the fact that his/her life is at a greater risk.

Gullible people will rush in to donate from the lure of a large amount of money only to discover in later years that their health may be affected a lot more than they realised.

• As with the current system, no one can walk into a hospital off the street, sign a form and then lay down on the operating table. People wanting to give organs must take legal counsel before signing so as to aid them in understanding the full ramifications of what their decision will be. Apart from exceptional life and death situations, there probably would be a mandatory cooling off period of two weeks between agreeing and operation.
• However one must also remember there are always two parties involved. Is it still better for a totally innocent potential recipient to definitely die than for the possibility that an irresponsible person makes a negligent decision with regards to his health?

This will be a law that can only benefit rich people. How can a poor person suffering organ failure be able to get his hands of $50,000 to $100,000 for a transplant?

• People can still donate their organs or sell at below market rates, if they wish to assist low income people.
• If the ailing person is well known in his or her community it is also possible that charitable organisations may come to the rescue. However even when that is not the case, are we to embrace the less that noble principle that if the ailing poor cannot be saved then we must ensure, for the sake of equity, that the ailing rich must also die.

Doctors and medical societies often contribute to policy debates.  Medicine and science connote objectivity and the public may innocently assume that contributions from the medical profession are merely dispassionate facts which lack political and ideological intrusion. However, the medical profession, like every other human endeavour operates within the realm of the human condition. In this context it is wholly expected that there will be a natural tendency for the opinion and political agendas of doctors to be communicated as if they were based on science and research.

To coincide with the climate change meeting in Cancun, Mexico, The Lancet medical journal is promoting The Climate and Health Council (CHC) which was “established to enable health professionals around the world to take personal and collective action against the causes of climate change, and to insist that global health is central in climate change negotiations.” Implicit is an appeal  that based on “evidence” and research doctors have an obligation, if not moral duty, to support, amongst various actions, carbon emission reduction strategies.

However, is it ethical for doctors to be promoting such strategies under the guise of public health? The strategies to reduce to carbon emissions must, necessarily, force some people to adopt behaviour against their will in order for the benefit of others. This defines an ethical dilemma, trading the welfare of current versus future generations. In modern ethics the principle of autonomy reigns supreme. However, autonomy is legitimately overruled when there is a compelling argument under the ethical principle of justice. Is there a compelling case?

Many, including The Lancet, still unquestionably reference the Stern Review in order to justify the benefits of “action” now, despite significant controversy over Stern’s extraordinarily pessimistic assumptions. To be sure, within Stern’s review the supposed health effects have been factored in to the costs of global warming along with other non-market factors.  Yet many economists such as Indur Goklany demonstrate that even if we were to accept Stern’s questionable assumptions, tomorrows generations will still be far better off than we are today; even if we do nothing about global warming. For instance, inaction on climate change will mean those living in a hundred years will ONLY be 3 to 7.5 times better off than we are today instead of 3.2 to 8 times. If we do nothing, descendents of those living in the current developing world will only be 10 to 60 instead of 11 to 65 times better off.  The developing world is where children still die for want of food, millions of women continuously leak faeces and urine for the rest of their lives for want of a basic medical care at birth and where millions die from easily preventable diseases that are almost unheard of in developed countries. There exists the real potential that many in the developing world will be sacrificed on the altar of politically-correct ideology. In even the most pessimistic analysis, the potential health effects of climate change are dwarfed by those caused by lack of economic development.

Furthermore, is it ethical to justify “action now” to protect the welfare of future generations based on the following preposterous assumptions? Zero technological advances; future generations will make no attempt to adapt to climate change; no ways to better peoples’ lives will be discovered including no cures for cancer and chronic diseases and no development of social institutions to foster peace and freedom; and Stern’s use of a near zero discount rate which many incorrectly believe represents ethical parity between generations, but in fact values those in the future more than those now.

Common sense dictates that there is a relationship between the degree to which a system is complex and the opportunity for ideology to influence the reporting of the science. In clinical medicine debate can rage for decades over the effect of a single drug used in a single situation. Despite the fact that trials can be done and empiric data collected there are always factors and elements that can be disputed. Consider then, the difficulty in trying to predict the health effects of changing climates hundreds of years down the track in a world in which we cannot fathom the available technology and economic development.

In this context, to whatever the degree the climate science is “settled”, the evidence currently available to analyse the health effects of climate change is contemptuously feeble. Many of the supposed health consequences such as food and water scarcity, infectious diseases and exposure to heat relate to the developing world and are easily remedied by measures already available to those in developed nations. Much of that evidence conforms to anti-west ideology that ignores the elephant in the room concerning economic development. Much of the data relating to the potential effects on the developed world is already obsolete subsequent to the implementation of simple public health measures. Overall, is the health of those in the developed world severely worse than that of our ancestors 150 years ago because the world has warmed 1.5 degrees?

The Chasers would do well to set up a stall in Broadmeadows and ask people on the street to reduce their economic welfare so those in Toorak can avoid the catastrophe of being a mere 10 times better off than Broadmeadows residents instead of 10.5 times.

If we’re considering such an important issue as people’s health why do we continue to rely on the analyses of single, politically appointed economists with no significant history in climate economics such as Stern and Ross Garnaut? A Group of economists seasoned in many aspects of climate change economics (Copenhagen Consensus) have performed a far more compelling analysis that places carbon reduction as one the most inefficient ways to improve health and welfare.

Revealingly, the CHC declare on their “about” page: “Thirty years ago, health professionals from the USA and the former Soviet Union crossed borders to found the International Physicians for the Prevention of Nuclear War movement, an international body of health professionals dedicated to action against nuclear war. Today we will initiate an equally global movement of health professionals to tackle climate change.” (There is nothing wrong with the prevention of nuclear war; it is a noble goal, but it is not related to the health effects of global warming.)

In summary, it is legitimate to hold a political opinion regarding action on global warming. But from a public health perspective it would be equally valid to argue for as many coal-fired power plants to be built in Africa, India and China etc as is humanly possible.

In light of the Ben Cousins documentary, there needs to be some clarification about what actions and behaviours people are and are not responsible for when taking drugs.

As opposed to the many highly functional business executives, doctors, lawyers, trades people, artists, police officers, service employees, farmers, small business owners etc who use these drugs, most of the harm that befell Ben was due to behaviour for which he should be held responsible for.

In fact the vast majority of users of these drugs do not act as recklessly as Ben. In this context, readers might appreciate clarification about the extent to which behaviours can be explained on a “disease” versus that of culpable lack of responsibility.

A number of quotes from Ben demonstrate that his actions were not due to a “disease.” They were essentially due to dysfunctional behaviour due to decisions he made.

Ultimately, people do have the option of whether to take drugs or not. Yes, some people are pre-disposed to have strong urges to take drugs. Some people experience intense feelings of internal turmoil for which drugs give temporary relief.  We should be very sympathetic to their plight and offer help. However, if drug use is hurting their lives, they have a responsibility to get help; not selfishly continue what they are doing and then blame it on “my drug disease”.

This is similar to the scandal whereby people are let off violent crime because they have a “drug problem.”

From a pharmacological, ethical, moral and philosophical perspective, taking these drugs is no different to drinking alcohol.

In this context we should not punish people who use drugs but are otherwise good citizens. We should however punish people who commit crime whether they take drugs or not. Criminal activity is not part of a “disease”; that’s a cop out.

About Dr Michael Keane

Dr Michael Keane is a consultant anaesthetist and bioethicist. He is also a National Health and Medical Research Council (NH&MRC) funded researcher into illicit drugs.

He holds the following positions:

Lecturer in public health at Monash University

Researcher at Swinburne University’s Brain Sciences Institute

Researcher at the University of Adelaide

1) Why support injecting rooms?

Heroin injecting rooms:

• will prevent overdoses and help minimise harm;
• reduce pressure on ambulance and paramedic services that will free them up to attend other calls;
• reduce the number of used syringes that are left in public places;
• enable heroin users to be in contact with health services and to promote programs to help end heroin dependency

2) With rights comes responsibility

The use of, or withdrawal from, heroin is not an excuse for committing violent or property crime. Heroin does not stop you knowing right from wrong and you maintain responsibility for your behaviour.

We should not spend valuable police resources on those people who merely take heroin and don’t hurt others. We should offer these poor souls help to end what is a terrible existence.

We should however, protect the community from those who do the wrong thing and commit crime. Heroin users who commit violent crime or serious property crime should be held accountable and not be given a free pass.

The debate has been hijacked by those who only see one side of the issue. On the one hand there are many who want to take a “tough on drugs” stance. On the other side are those who refuse to hold accountable the minority of heroin users who commit crime; they wrongly excuse crime on the users “disease”.

If a heroin user steals a car or assaults someone, they should be properly identified as a criminal. If their crime is treated as a “disease” then the public is understandably going to want to take a “tough on drugs” stance against all people who take heroin.

Dependency on heroin can be thought of as a disease and we should show compassion and help those afflicted. But crime against others is not a disease. Criminals should be held accountable before the law.

For those interested in more information on the science behind:

• the basis for holding heroin users accountable for their behaviour;
• the reason why the vast majority of the population would not become addicted to heroin even if laws were relaxed

About Dr Michael Keane

Dr Michael Keane is a consultant anaesthetist and bioethicist. He is also a National Health and Medical Research Council (NH&MRC) funded researcher into illicit drugs.

He holds the following positions:

Lecturer in public health at Monash University

Researcher at Swinburne University’s Brain Sciences Institute

Researcher at the University of Adelaide