The study results are striking. By surveying 46 healthcare professionals, Rottman and co-authors highlight that hospital clinicians are unaware of the general and ethical challenges that occur during a pandemic. Moreover, the study shows that when hospital clinicians are made aware of the potential challenges, including triage and resource allocation decision scenarios, they are “quickly overwhelmed” and unable to reason through the scenarios and/or draw upon cohesive and consistent response action plans. This study is immensely helpful in that it demonstrates the acute preparedness and knowledge gaps regarding ethical decision- making, although the results would be statistically stronger with a larger respondent pool. This information is highly relevant because a failure by the clinical community to make ethical decisions in a pandemic not only exposes the clinician and his or her hospital to legal liability, but also is likely to lead to a failure to save the most amount of lives possible. For example, without preparedness in ethical decision-making, a clinician may decide to allocate resources and provide care on a first-come, first-served basis or lottery system. Although these two systems might seem superficially fair, this type of decision-making is not likely to maximize the total number of lives saved. Additionally, because select survey responses extend beyond pandemics to include bioterrorism and disasters generally, the study results may be applicable for consideration in multiple hazard disaster planning.

Continue reading editorial and study results at the journal of Prehospital and Disaster Medicine.

Dr Mark Gasson from the University of Reading contaminated a computer chip which was then inserted into his hand. The device, which enables him to pass through security doors and activate his mobile phone, is a sophisticated version of ID chips used to tag pets.

In trials, Dr Gasson showed that the chip was able to pass on the computer virus to external control systems.  If other implanted chips had then connected to the system they too would have been corrupted, he said.

Medical alert

Dr Gasson admits that the test is a proof of principle but he thinks it has important implications for a future where medical devices such as pacemakers and cochlear implants become more sophisticated, and risk being contaminated by other human implants. 

“With the benefits of this type of technology come risks. We may improve ourselves in some way but much like the improvements with other technologies, mobile phones for example, they become vulnerable to risks, such as security problems and computer viruses.”

However, Dr Gasson predicts that wider use will be made of implanted technology.

“This type of technology has been commercialised in the United States as a type of medical alert bracelet, so that if you’re found unconscious you can be scanned and your medical history brought up.”

Professor Rafael Capurro of the Steinbeis-Transfer-Institute of Information Ethics in Germany told BBC News that the research was “interesting”.

“If someone can get online access to your implant, it could be serious,” he said.

Cosmetic surgery

Professor Capurro contributed to a 2005 ethical study for the European Commission that looked at the development of digital implants and possible abuse of them. 

“From an ethical point of view, the surveillance of implants can be both positive and negative,” he said.

“Surveillance can be part of medical care, but if someone wants to do harm to you, it could be a problem.”

In addition, he said, that there should be caution if implants with surveillance capabilities started to be used outside of a medical setting.

However, Dr Gasson believes that there will be a demand for these non-essential applications, much as people pay for cosmetic surgery.

“If we can find a way of enhancing someone’s memory or their IQ then there’s a real possibility that people will choose to have this kind of invasive procedure.”

Dr Gasson works at the University of Reading’s School of Systems Engineering and will present the results of his research at the International Symposium for Technology and Society in Australia next month. Professor Capurro will also talk at the event.

By Rory Cellan-Jones Technology correspondent, BBC News Page last updated at 7:20 GMT, Wednesday, 26 May 2010 8:20 UK http://news.bbc.co.uk/2/hi/technology/10158517.stm

But it wasn’t always so. In the 1970s and ’80s, companies raced to get out of the vaccine business because of the high manufacturing costs, the high chance of failure, and the threat of lawsuits if patients suffered adverse side effects. But then the federal government passed the Childhood Vaccine Injury Act in 1986, which created a pool of money for patients who experienced adverse effects and shielded companies from lawsuits. Advances in technology have driven manufacturing costs down. “And companies have seen that if a vaccine is on a government program, one doesn’t have to spend money to promote it,” Bogorad said.

The market is dominated by a handful of global players, including U.K.-based GlaxoSmithKline, France’s Sanofi Pasteur, Wyeth, which has now merged with New York-based Pfizer Inc., Switzerland’s Novartis AG and Merck and Co. Inc. of New Jersey. This makes it difficult for smaller players to break in.

But this cadre of vaccine giants relies on an ecosystem of smaller companies to fill its pipeline with preventive therapies. And that pipeline could grow now that the Bill and Melinda Gates Foundation has pledged $10 billion to fund vaccine research.

Bogorad said New England provides a ripe landscape for mergers and acquisitions. Case in point is Acambis. The Cambridge company, which has potential vaccines targeting herpes, influenza, dengue fever and West Nile virus, was bought last year by Sanofi Pasteur for $548 million.

One local vaccine company that has been growing independently is Xcellerex Inc. The Marlborough company was founded in 2004, has 120 employees and is cash-flow positive. Xcellerex provides outsourced manufacturing services and equipment, using a disposable system that eliminates the need for steam sterilization of bioreactors used to make vaccines and other biologics. CEO Joe Zakrzewski said the method cuts down on the chances for contamination of vaccines or other products.

Zakrzewski claims that the process can speed up getting a product to market and that clinical trials using the technology can cost one fourth that of clinical trials using traditional biologics manufacturing methods. Xcellerex’s clients include Cambridge-based Acceleron Pharma Inc., whose lead product is a biotherapeutic designed to increase red blood cell and bone formation and is in Phase 2 clinical trials.

Xcellerex also develops its own therapeutics and has launched a Phase 1 clinical trial for a potential vaccine targeting yellow fever. Bogorad and other analysts say that the travel vaccine market is a small segment of the market, but Zakzrewski said there is still money to be made. “Right now, it’s a $100 million market. But 90 percent of the people who need the yellow-fever vaccine don’t get it, because the risks of the current vaccine are too high. So we love it when people say the market is small. We think it could be $1 billion.”

Xcellerex officials say that their vaccine candidate is fundamentally different from current vaccines because it uses a dead virus rather than a live one. Xcellerex has partnered with other companies on manufacturing four or five vaccines in the past. In October, the company announced it would partner with Rockville, Md.-based Novavax to ramp up large-scale manufacturing for its H1N1 vaccine.

The perils of this high-stakes business can be seen across New England. Protein Sciences Corp., in Meridien, Conn., received a blow when the U.S. Food and Drug Administration rejected its potential flu vaccine this fall, because the agency wanted more safety data. Analysts and public health officials had been watching the progress of the potential vaccine because it would represent a novel breakthrough. While current vaccines for influenza are made from fertilized chicken eggs, which is slow and expensive, the Protein Sciences target aims to produce flu cells in caterpillars.

Antigenics Inc., in Lexington, also faced a regulatory setback this fall when European authorities rejected its potential cancer vaccine, called Oncophage. Cancer vaccines have been an elusive target so far, but officials in area companies say that is going to change.

“We (in the industry) are starting to learn from our mistakes. It’s not a matter of if, but when,” said Eric Von Hofe, CEO of Antigen Express Inc. The Worcester-based vaccine developer is working on targets using synthetic peptides, which are protein fragments, that Von Hofe says can be manufactured more quickly than the traditional chicken-egg method. Von Hofe is reporting positive interim results for a Phase 2 vaccine study targeting breast cancer. But so far, no synthetic vaccines have been approved by the FDA. 

In theory, CER sounds like a calm, academic subject: evaluate different treatment options for a given illness — drug A vs drug B, or drug A vs surgery — and determine which does a better job of reducing morbidity and mortality. You also can go a step further and compare these treatment options in terms of risks or cost-effectiveness: Does drug B outperform drug A by a 2% margin but cost 3 times as much? Experts say such research is in short supply, leading to poorer clinical outcomes and runaway costs.

However, talk of government-sponsored CER pushes hot buttons in medicine and American society alike, being called “rationing” and “government takeover of medicine.” For proof, consider what happened when the US Preventive Services Task Force announced last November that, based on the scientific evidence it weighed, it no longer recommends mammograms for women aged 40 through 49 years. The task force also recommended that women aged 50 years and older no longer receive annual mammograms but, instead, get them every other year. Public outcry and pushback from several medical societies and expert groups like the American Cancer Society swayed Senate Democrats to rewrite their pending healthcare reform legislation to guarantee mammogram coverage.

If Congress enacts healthcare reform, more such medical recommendations could roil Americans. That’s because reform bills passed by the House and Senate (which have yet to be reconciled) call for the creation of a CER entity that would question the value of many trusted procedures and treatments. These provisions come on top of economic stimulus legislation passed in early 2009 that pumps $1.1 billion into CER and establishes a new federal bureaucracy to manage it. The government would not conduct CER itself by and large but would instead fund the work of academic investigators.

NEJM Authors Bolster Support for CER Individual physicians and medical societies approach CER with varying degrees of enthusiasm, cautious support, and downright fear and loathing. The 2 recent NEJM articles seek to bolster support for this controversial discipline. Two professors at Weill Cornell Medical College, New York City, write in an article titled “Health Care Reform and the Need for Comparative-Effectiveness Research” that CER is “physicians’ first line of defense against blind cost containment.” Furthermore, it could spur drug and medical device manufacturers “to develop products that really matter.” “I think CER is the physician’s best friend,” coauthor Alvin Mushlin, MD, professor and chair of the Department of Public Health at Weill Cornell, told Medscape Medical News. Similarly, the other NEJM article, titled “Comparative Effectiveness and Health Care Spending — Implications for Reform,” warns that without a shift to best-bang-for-the-buck services identified by CER, cost-cutting alone could produce worse health outcomes. “If we can induce hospitals and health plans to improve efficiency and not just cut costs, then health costs in the United States will come down and outcomes will improve,” write coauthors Milton Weinstein, PhD, a professor of health policy and management at the Harvard School of Public Health, Boston, Massachusetts, and Jonathan Skinner, PhD, a professor of economics at Dartmouth Medical School, Hanover, New Hampshire. Proposed Government-Sponsored CER Would Be Transparent The American Medical Association (AMA) and several other medical societies believe that the federal government can play a valuable role in CER. After all, the cost of this research deters drug and device manufacturers from studying how their products fare in head-to-head competition with others; plus, they may be afraid to tell the world that their product is second-best, according to AMA President J. James Rohack, MD. The government would not operate under these constraints. Furthermore, government-sponsored CER would be a public, transparent enterprise. In contrast, said Dr. Rohack, private payers that conduct CER to determine what they’ll cover don’t always reveal how they’ve reached their decisions — the proverbial, and hated, black box. “You don’t know if they’re just trying to maximize profits or if science backs up their coverage determination,” Dr. Rohack told Medscape Medical News. Accordingly, the AMA and its medical allies have mostly supported provisions in healthcare reform legislation that make the federal government a player in CER. The House bill establishes a Center for Comparative Effectiveness Research within the Agency for Healthcare Research and Quality in the US Department of Health and Human Services. Findings from this center could not be construed as mandates regarding treatment, coverage, or payment, but some experts interpret the legislation as giving the center the ability to make recommendations. In contrast, the Senate bill would create a nonprofit, independent Patient-Centered Outcomes Research Institute that is confined to only publishing its findings and is explicitly prohibited from issuing even recommendations. The AMA prefers the Senate approach because it’s more emphatic about denying a CER body any policy-making clout. The association also prefers an independent body. In contrast, the CER center in the House bill would be a fiefdom within Department of Health and Human Services, which also operates the Medicare and Medicaid programs. There’s fear in some quarters that a CER group embedded in the federal bureaucracy would be vulnerable to political bullying, with scientific integrity sacrificed on the altar of budget-cutting. However, an independent body also comes with risks, said Neil Kirschner, PhD, a senior associate in regulatory and insurer affairs for the American College of Physicians (ACP), a strong advocate of government-sponsored CER. “The public-private group that the Senate wants could be unduly influenced by the private sector,” Dr. Kirschner told Medscape Medical News. “The ACP hasn’t taken a position on which approach is right.” Dr. Kirschner said the ACP would like government-sponsored CER to freely factor in cost-effectiveness data. “The Senate bill makes this more difficult,” he said. “The House bill is more silent on the use of cost.” Cost-effectiveness, he added, doesn’t necessarily mean adopting the least-expensive treatment. “Sometimes the most expensive treatment may be a better value by helping a person live much longer,” he said. Give Physicians Scientific Findings, Not Recommendations Both the ACP and the AMA agree that a government-sponsored CER body should forgo recommendations, much less mandates, on how physicians should practice medicine. For one thing, private insurers and government programs like Medicare are tempted to turn such recommendations into binding policies that may arbitrarily deny patients coverage for needed care, explained the AMA’s Dr. Rohack. “Look at vaccines,” Dr. Rohack told Medscape Medical News. “The federal Advisory Committee on Immunization Practices recommends what vaccines should be administered, and insurers key off that to determine what they’ll pay for.” The fracas over mammograms last year occurred at the intersection of recommendation and insurance coverage, noted health-policy analyst Dennis Smith from the Heritage Foundation, a conservative think tank. “The essential benefit package in the [original] Senate reform bill was supposed to include preventive services recommended by the US Preventive Services Task Force. So if you didn’t meet the [task force] criteria, you wouldn’t get your mammogram paid for.” Dr. Rohack also pointed to the problem of inflexible application of CER. A study that identifies the best way to treat a particular medical condition may have excluded patients older than 65 years, for example. A payer may then decide to cover that treatment, but not for anyone older than 65 years, he said. It’s sufficient, said Dr. Rohack, to give CER findings to physicians and patients and let them make the final decision on medical care. “Physicians by training try to use evidence-based science to do what’s best for patients,” he said. “If there is a gray zone, they’ll rely on history, experience, and local practice styles. And there are gray zones.” Dr. Rushlin at Weill Cornell Medical College agrees with Dr. Rohack that merely publishing CER findings without adding recommendations will benefit healthcare. “We need to get started incorporating information from CER into the public debate on healthcare. It can be a very positive step in the right direction,” he said. “When you put the evidence on the table, it illuminates the discussion. It doesn’t eliminate the discussion. That’s healthy.” Rationing With a Light Touch? Despite all the restrictions in the House and Senate healthcare reform bills, government-sponsored CER alarms some physicians, such as the American Association of Physicians and Surgeons. An opponent of reform legislation, the society states on its Web site that CER “will provide the rationale for rationing” and suggests that this discipline is a reincarnation of managed care. Sen. Thomas Coburn, MD (R-OK), wrote in the Wall Street Journal last month that CER is one reason why “seniors will die sooner” if Congress passes the Senate’s version of healthcare reform. In other countries, such as the United Kingdom, Dr. Coburn wrote, CER panels amount to rationing panels. Dr. Weinstein and Dr. Skinner acknowledge in their article that Americans have less of a stomach for explicit, top-down rationing of healthcare resources than other countries in which CER has a longer history. The authors point out, however, that Americans appear more amenable to rationing when it’s based on free-market price decisions, such as whether to pay a higher copayment for more expensive medication. With that tendency in mind, Dr. Weinstein and Dr. Skinner suggest several ways to coax patients and providers to veer toward cost-effective care without getting heavy-handed about it. Physicians and hospitals could receive higher compensation when they perform more cost-effective services, and lower compensation when they choose more wasteful services. Likewise, consumers purchasing insurance could pay a higher premium for a plan that would give them immediate access to higher-cost medications, for example, without first having to try less expensive ones — read generics — to see whether they work. N Engl J Med. Published online January 6, 2010.

The woman could not have another child because of her physical condition and age, says Luo. “She wept in front of me and I was really moved. They had my sympathy and I felt that I can do something for them.” In January, Luo gave birth to a baby girl. “It was not as painful as with my first delivery,” Luo recalls. “I was relieved that she was healthy and I knew all along that it was the couple’s baby, not mine, to detach myself,” she says.

Luo declines to reveal how much she got paid for the labor, but admitted it was enough for her to pay off her husband’s debt. Lu Jinfeng, founder of an online surrogacy agency, says surrogate mothers act out of compassion, but also according to their own financial woes. “In most cases, they are facing economic hardships either because of medical bills from family members or business or marriage failures, such as divorced women who cannot afford raising kids on their own,” says Lu. More clients are looking for surrogate mothers since Lu launched his online agency in 2004. They are mostly couples from big modern cities such as Guangzhou, Beijing, Shanghai, Shenzhen or from overseas, given the wives are unable to bear children but can still produce healthy eggs, says Lu. Some others come up to Lu for hope in sorrow: their children died in accidents and they are too old to bear new babies. The infertility rate among Chinese couples is up to 15 percent, and women shoulder the causes in nearly half cases. But less than one third of the infertile women can be cured with medical treatment. “These couples suffer from being childless.

A family without a child is incomplete in Chinese culture,” he says. Mr. Wang, a 37-year-old peasant from Anhui Province, married his teenage sweetheart 16 years ago.

After repeated attempts for having babies failed, his wife was diagnosed as having endometrial adhesion, which left her unable to carry a baby. “We’ve tried every possible solution, both from experts in big cities and folk remedies, but none of them ever worked,” Wang says. “Whenever we see couples with kids, we feel both envious and sad. We want a happy family, a family with a child.” The couple became subject of rumors in their village. “In the countryside, people are superstitious. When they notice you are still childless several years after marriage, they make up all kinds of stories.” The couple eventually left to find jobs in the city, and to get away from the pressure from family and gossips. Now a small businessman in Guangzhou, Wang and his wife are happier because they are expecting a baby, carried by a surrogate mother. “The pregnancy is already six months through now,” Wang says. “We don’t mind whether it’s a boy or a girl. We’re ecstatic that we are going to have a baby.” Wang first heard of surrogacy a couple of years ago, when one of his friends signed a surrogate mother through an agency and succeeded in parenting a baby girl. “I’ve got a lot of doubts in mind at the very beginning, the most important of which is whether the baby will be healthy. I’ve been witnessing my friend’s baby girl growing in perfect condition for two years,” Wang says. According to the Wangs’ agreement with a surrogate mother, a 32-year-old divorcee who has a son of herself, the couple will pay100,000 yuan (14,706 U.S. dollars) upon the arrival of a newborn, plus a monthly allowance of 2,500 yuan (368 U.S. dollars) during her pregnancy. “We are very grateful to her, and I think it’s reasonable to pay her for bringing a baby into our live,” Wang says. The total cost amounts to more than 200,000 yuan (29,412 U.S. dollars), including medical expenses, in-vitro fertilization and delivery, and a nanny to take care of the surrogate mother. Wang says his wife visits the surrogate mother almost every week. The couple is still concerned that she will become too attached to the to-be-born, although she has learnt from the beginning that it was their child and she was just helping them. Xiao Luo feels the same. She has never seen the baby girl after delivery as agreed in advance with the parents. “Sometimes I would wonder how she looks like. She should be happy together with her loving parents,” she says. With growing demands for surrogate mothers, underground networks of surrogacy agents have spread over the recent years, making lucrative profits. For Lu’s agency, commission fee ranges from 12,000 to 15,000 yuan (1,765 to 2,206 U.S. dollars) for one surrogate mother. Two types of surrogacy are in service at the moment: one through in-vitro fertilization with the clients’ eggs and sperms; the other through test-tube fertilization with eggs from surrogate mothers. To avoid disputes, Lu’s agency has denied requests for surrogacy with donated eggs because of the high risk of the surrogate mother becoming too attached to the child to give it away. Source:Xinhua The legitimacy of surrogacy in China is open to question. In 2001, the Ministry of Health issued regulations on human assisted reproduction technology, which prohibits medical institutions and medical workers from conducting any kind of surrogacy treatments. However, surrogacy agencies argue they are exempt from the regulations, which only ban medical institutions and medical workers from conducting surrogacy treatments. Lu, whose agency has successfully helped with more than 2,000 surrogate children, declines to give any information about where and how the treatments are conducted. His agency charges 20,000 to70,000 yuan (2,941 to 10.294 U.S. dollars) for matchmaking hospitals with clients, according to the agency’s website. Professor Li Benfu, medical ethics expert at Peking University Health Science Center, says the surrogacy is very risky with the current legal status and will lead to serious problems, with commercial surrogacy in particular. “There’s always risk of complications or even death for the pregnant women and the risk of a baby born with birth defects,” says Li. “the problem is who will take responsibility if these situations occur?” But Li also acknowledges the fact that some women cannot bear a child by themselves even though they produce healthy eggs. “Banning surrogacy virtually deprives these women of the right to reproduction,” he says. He suggests making rules for surrogacy instead of completely banning it. But with the number of surrogate birth is still very small, the prospect of a safe legal framework remains distant, he says. Lu agrees: “There should be specific regulations regarding surrogacy agencies. For example, health authorities can set strict standards and issue certificates to qualified agencies.” Liang Xiao, partner at a law firm based in Foshan, Guangdong Province, has received a couple seeking for legal advice about their dispute with a surrogate mother, a divorced woman who bore a baby with the couple’s sperm and egg but refused to give them the child after delivery as agreed. “They did not file a lawsuit in the end, but the case raised a lot of concerns,” Liang says. Current Chinese laws did not apply to the case, Liang says. A circular issued by the Supreme People’s Court states that if a married couple agree to have artificial fertilization, the child is regarded as their marital child and their rights and duties are subject to the Marriage Law. “But the parentage of children carried by surrogate mothers has yet been defined by law, thus causing disputes,” Liang says. He suggests that it is necessary to notarize surrogacy agreements by official institutions, in addition to technical regulations defining which organizations are allowed to conduct surrogacy treatment, as well as strict management and supervision of the medical institutions and professionals. Liang argues the regulations should make it a rule that couples seeking for surrogacy must prove they are legally married and the wife is unable to bear a child, and those who violate the regulations should be severely punished. “Because this problem hasn’t yet sparked widespread social interest, so the government hasn’t started doing anything about it,” says Lu Jinfeng. To legislate surrogacy is not yet on the agenda, according to the information office of the Ministry of Health. Medical institutions and doctors that perform surrogacy operations can be fined up to 30,000 yuan (4,412 U.S. dollars), according to current regulations on human-assisted reproduction technology. The Ministry has no figures of institutions or medical staff that have been punished since the regulations took effect in 2001. However, an official from a district family-planning office in Guangzhou who asks not to be named, says doctors who perform in-vitro fertilizations get bonuses of about 40,000 yuan (5,882 U.S. dollars) and the surrogacy industry is valued in the millions of yuan each year. In February last year, the family-planning office found three women in a communal flat were acting as “illegal” surrogates and all of them had “agreed” to undergo “remedial measures” in accordance with the law, said the official. Existing in a gray zone, surrogacy agencies are alleged to have arranged prostitution, and blackmailed or defrauded clients. “It is high time for the government to map out surrogacy regulations and clean up the industry, says Lu, “we are willing to come under supervision and sunshine.” But he says commercial surrogacy should never be allowed. “Some rich women rent a womb simply because they want to keep fit — that is absolutely not acceptable.”

More than 20,000 organ transplants take place every year in the United States, with a vast majority coming from deceased donors. Demand greatly exceeds supply: in 2006, for example, 3,916 patients died while waiting for kidneys, according to the National Kidney Foundation.

Some economists have come up with a simple solution: a market allowing the buying and selling of organs. Because people have two kidneys and need only one to live, a robust market could greatly increase supply.

The idea may have some merit, but it is spectacularly unpopular. As the Harvard economist Alvin Roth has noted, many people consider it “repugnant,” mainly for two reasons. First, they object to the possibility of rich people buying their way to the front of the line. (The hospital where Mr. Jobs’s procedure took place said he received the liver transplant because he was the sickest person on its waiting list who matched the donor’s blood type.) Second, they object to incentives that would induce the poor to sell their kidneys.

These objections can lead to some logical quandaries. Why, for example, is it O.K. for a parent to donate a kidney to save a child’s life but not for her to sell her kidney, thereby also saving a life? And why is it acceptable to risk your life for money, say, by becoming a coal miner, but not by selling a kidney?

Still, whether you think a legal market for organs is a brilliant or a dreadful idea, it’s a political nonstarter, so it is important to obtain donors from another possible source: patients who have been declared “brain dead” but are being kept alive temporarily.

Nationwide, roughly 12,000 to 15,000 people fall into this category each year, but only half end up as donors. Because each such donor could supply an average of three organs, having another thousand donors could save 3,000 lives. We need more people to agree to be donors in advance.

One strategy is to alter the default rules for signup. Most states, as well as many other countries, use an “opt in” or “explicit consent” rule, meaning that people must take a concrete action, like going to a public library or requesting and mailing in a form, to declare they want to be donors. But many who are willing to donate organs never get around to such steps.

An alternative approach, used in several European countries, is an “opt out” rule, often called “presumed consent,” in which citizens are presumed to be consenting donors unless they act to register their unwillingness.

In the world of traditional economics, it shouldn’t matter whether you use an opt-in or opt-out system. So long as the costs of registering as a donor or a nondonor are low, the results should be similar. But many findings of behavioral economics show that tiny disparities in such rules can make a big difference.

By comparing the consent rates in European countries, the psychologists Eric Johnson and Dan Goldstein have shown that the choice of opting in or opting out is a major factor.

Consider the difference in consent rates between two similar countries, Austria and Germany. In Germany, which uses an opt-in system, only 12 percent give their consent; in Austria, which uses opt-out, nearly everyone (99 percent) does.

Although presumed consent is generally accepted in countries that have adopted it, the idea can bring strong opposition. Many people object to anyone presuming anything about their organs, even if the costs of opting out are low. In Britain, a proposal by the Labour government to adopt an opt-out system was opposed by Muslims who objected to organ removal on religious grounds.

Fortunately, there is another possibility, called “mandated choice,” under which people must indicate their preference. In Illinois, where I live, this system has been in use since 2006 and doesn’t seem to have ruffled many feathers.

Here is how it works: When you go to renew your driver’s license and update your photograph, you are required to answer this question: “Do you wish to be an organ donor?” The state now has a 60 percent donor signup rate, according to Donate Life Illinois, a coalition of agencies. That is much higher than the national rate of 38 percent reported by Donate Life America

The Illinois system has another advantage. There can be legal conflicts over whether registering intent is enough to qualify you as an organ donor or whether a doctor must still ask your family’s permission. In France, for example, although there is technically a presumed-consent law, in practice doctors still seek relatives’ approval. In Illinois, the First-Person Consent Law, which created this system, makes one’s wishes to be a donor legally binding. Thus, mandated choice may achieve a higher rate of donations than presumed consent, and avoid upsetting those who object to presumed consent for whatever reasons. This is a winning combination.

THE key, however, is to make signup easy, and requiring people to make a choice is just one way to accomplish it. The private sector could help create other simple methods. Here is a challenge to Mr. Jobs: Why not create a Web site — and a free app for the iPhone — that lets people sign up as organ donors in their home states?

At the same time, he’d need to work with the states to create the technology for a secure, simple signup procedure. Social networking sites like Facebook could also help, by encouraging signup campaigns.

Many Americans say they want to be organ donors, but they just don’t get around to acting on their intentions. Helping these potential good Samaritans overcome their inertia could prolong thousands of lives a year. Signing up to be an organ donor should be at least as easy as downloading a song to your iPhone.

Although the overall aim is to lower the nation’s healthcare costs and create access to healthcare for America’s 46 million uninsured, many aspects of the plans could have a huge impact on physicians.

Several healthcare reform plans are being proposed. Major discussions now revolve around elements in the Affordable Health Choices Act of 2009 (H.R. 3200), passed on July 31, 2009 by the House Energy and Commerce Committee.

The proposed plan is over 1000 pages long and addresses numerous aspects of healthcare. Some are generally considered beneficial, such as preventing insurers from denying coverage for previously existing conditions. Other features may run counter to physician interests.

Here is how the 3 major points of H.R. 3200 could affect physicians.

Public Option Plan

Summary: The government will develop low-premium insurance coverage to be offered to the public to compete with employer-sponsored plans. The public option will be a popular low-cost alternative and is intended to spur private insurance companies to lower their premiums to stay competitive.

Until mid-August, the intention was for reimbursement, rates to providers would be based on Medicare rates. However, in the newest development, the government would negotiate reimbursement rates directly with physicians. The rates could not be lower than Medicare rates, but couldn’t be higher than the average rates paid by provider plans.

The public option insurance plan would be required to pay for itself through premiums collected. It would not be funded by the US Treasury.

The plan would be optional for providers, who could choose whether or not to participate (Table 1).

Table 1. Pros and Cons of the Public Plan Option

 Individual Mandate

Summary: This element would require all individuals to have “acceptable health coverage.” People would be required to carry at least a minimal catastrophic policy to prevent catastrophic medical bills that bankrupt a percentage of US citizens each year.

Anyone without coverage will be charged a penalty of up to 2.5% of their modified adjusted gross income (up to the cost of the average national premium).

With the government insurance plan option, it is considered that carrying health insurance will be less of a burden for people who currently avoid health coverage because of cost (Table 2).

Table 2. Pros and Cons of the Individual Mandate Plan

Cost of Funding Healthcare Reform Plan

Summary: You won’t find many folks who deny that we need healthcare reform. Of course, expanded access to healthcare requires funding. Extended coverage to the uninsured has been estimated to cost in the range of $1 trillion over 10 years, and most of that will come from taxpayers. House Speaker Nancy Pelosi has claimed that she will push to “drain” more savings from the medical industry — hospitals, pharmaceutical companies, and health insurers, which will help fund healthcare reform.

Although H.R. 3200 does not specify the funding, proposals for doing so are under discussion. Current recommendations are to tax the most affluent. Individuals earning over $280,000 and households earning over $350,000 would have to pay a 1% surtax. Households earning from $500,000 to $1 million would have to pay a 1.5% surtax. Those tax rates could increase to 2% and 3% if the government does not achieve targeted cost savings. Pelosi would like the trigger raised to $500,000 for individuals and households with an adjusted gross income of $1 million or more (Table 3).

Table 3. Pros and Cons of the Cost of Funding Healthcare Reform Plan

Those Opposed Say:	Those in Favor Say:
Although physician incomes have been declining in recent years, $280,000 individual income is not out of line for many specialties and for high-earning primary care physicians or physicians holding directorial positions.	Because most Americans earn less than those amounts, it is not unreasonable to tax wealthier people when there is such a large disparity in income.
Would hurt small business owners and demotivate them to grow their businesses if they will be paying more in taxes.	Taxing the wealthy helps lessen the tax bite on the middle class and lower class, who can less afford it.
Taxing people who have huge educational debts and have worked hard to achieve a high income level is demotivating for American business people and for physicians who have achieved more credentials and expertise through hard work.
For physicians, this is money that they have earned, and many have gone deeply into dept through medical school and while earning minimum wage in residency. Taking it away is wrong, and fewer physicians will choose to go to medical school and remain in practice.
Government programs typically cost even more than they were budgeted at, which means that the proposed surcharge taxes would jump to an even higher level.

Other Key Points

A number of physicians have castigated H.R. 3200 for the issues that it does not address:

• Repayment of student loans: Repayment of student loans would help relieve numerous physicians of the financial pressures that they face. For new medical school graduates, student loans can range up to $225,000, according to The New England Journal of Medicine.
• Malpractice reform: H.R. 3200 does not address the malpractice issues that physicians face, and there appears to be no discussion of malpractice premiums, caps of awards, or other mechanisms to lessen the malpractice burden for physicians.

The survey was conducted by Boston-based brand communications firm PARTNERS+simons in June. The firm conducted an online survey of 800 people throughout Massachusetts between the ages of 25-65. These people were asked about their healthcare decision-making, and how they search for information about hospitals and doctors.

Surprisingly, only 24% trust their doctor completely to make the right decisions in terms of where they should go to receive medical care. When faced with choosing a hospital, only 5% agreed that hospitals are doing an excellent job educating them about why that facility is better than any another. That’s a provocative finding since a whopping 98% of respondents feel that, regardless of what people might say, not all hospitals deliver the same quality of care.

The survey also notes that:

• 58% of the respondents feel patients and their families should be actively involved in selecting the right hospital.
• 50% feel they need more and better information about quality and safety being delivered by doctors and hospitals.
• Today’s healthcare consumer is much more active than their parents were – respondents said they are 78% more likely to research information on physicians, and 75% more likely to evaluate treatment approaches.

”The physician referral system has been in place for a long time, and this study does not suggest it has become obsolete. But consumers are clearly beginning to question authority,” said Tony Cotrupi, President and head of the Health practice at PARTNERS+simons. “There is a profound opportunity for hospitals to better articulate their clinical expertise and commitment to the patient experience. The ones that meet this need for information will make patients less skeptical and, more importantly, true advocates for the hospital.”

In total disagreement, Professor Anjan Chatterjee from the University of Pennsylvania argues that there are too many risks in taking Ritalin unless you are actually ill. He notes that the Food and Drug Administration labelled it with a “black box” the most alarming of possible warnings. This is because there is a high potential for abuse, dependence, risk of sudden death and serious adverse effects on the heart, he says.

Chatterjee adds that there are cognitive trade-offs by taking Ritalin, for example a loss in creativity. He points out that “being smarter does not mean being wiser” and cites the very smart people who developed ways to distribute financial risk which in turn contributed to the current global economic crisis. 

Professor Chatterjee is also concerned about the end-goal of taking drugs to enhance cognitive abilities. He not only fears that children at top preparatory schools will end up taking Ritalin in “epidemic proportions” but asks whether pilots, the police and doctors on-call be pressurised into taking these drugs? 

In conclusion, Chatterjee does not believe it is acceptable to recommend that healthy people take Ritalin to enhance performance until proper safeguards are in place. Professor Harris, on the other hand, believes that these arguments are not persuasive. 

Harris on the contrary emphasises personal liberty and public safety. As no drug is side effect free, Harris believes Ritalin is “safe enough” given that children and young people with attention deficit hyperactivity disorder are routinely treated for long periods with it. 

Professor Harris adds that “humans are creatures that result from an enhancement process called evolution and moreover are inveterate self-improvers in every conceivable way.” 

Harris argues that change or progress often carries risk. The development of “synthetic sunshine” (firelights, lamplight and electric light), for example, could have forced people to work through the night. However, the answer was not to outlaw synthetic sunshine but to introduce laws to regulate working hours. “The same is or will be true of chemical cognitive enhancers,” he says. 

-British Medical Journal