Big Pharma: a former insider's view.

There is no lack of criticisms frequently levelled against the international pharmaceutical industry (Big Pharma): excessive profits, dubious or even dishonest practices, exploiting the sick and selective use of research data. Neither is there a shortage of examples used to support such opinions. A recent book by Brody (Hooked: Ethics, the Medical Profession and the Pharmaceutical Industry, 2008) provides a précis of the main areas of criticism, adopting a twofold strategy: (1) An assumption that the special nature and human need for pharmaceutical medicines requires that such products should not be treated like other commodities and (2) A multilevel descriptive approach that facilitates an ethical analysis of relationships and practices. At the same time, Brody is fully aware of the nature of the fundamental dilemma: the apparent addiction to (and denial of) the widespread availability of gifts and financial support for conferences etc., but recognises that 'Remove the industry and its products, and a considerable portion of scientific medicine's power to help the patient vanishes' (Brody 2008, p. 5). The paper explores some of the relevant issues, and argues that despite the identified shortcomings and a need for rigorous and perhaps enhanced regulation, and realistic price control, the commercially competitive pharmaceutical industry remains the best option for developing safer and more effective medicinal treatments. At the same time, adoption of a broader ethical basis for the industry's activities, such as a triple bottom line policy, would register an important move in the right direction and go some way toward answering critics.

Professional values in community and public health pharmacy.

General practice (community) pharmacy as a healthcare profession is largely devoted to therapeutic treatment of individual patients whether in dispensing medically authorised prescriptions or by providing members of the public with over-the-counter advice and service for a variety of common ailments. Recently, community pharmacy has been identified as an untapped resource available to undertake important aspects of public health and in particular health promotion. In contrast to therapeutic treatment, public health primarily concerns the health of the entire population, rather than the health of individuals (Childress et al. in J Law Med Ethics 30:170-178, 2002). Thus, an important question for the profession is whether those moral and professional values that are appropriate to the therapeutic care of individual patients are relevant and adequate to support the additional public health role.

Assisted dying: the influence of public opinion in an increasingly diverse society.

Attitudes to questions of whether physician-assisted dying should be legalised in the UK, reflect one of the greatest challenges to moral stance in health care for both individuals and professional bodies, not least as indicated by public opinion. However, public opinion is a seductively deceptive notion, seemingly readily identifiable but in practice multifarious. At best, consensus regarding public opinion and assisted dying is illusory, sometimes transient and what is relevant in this matter is a comprehension of both majority (popular) opinion and vocal dissent, but which do not them selves have a simple relationship with Parliamentary attitudes and legislation. Arguably, an increasingly important consideration to take account of is the influence of increasing population diversity.

Dignity under threat? A study of the experiences of older people in the United Kingdom.

Theoretical accounts have offered a general understanding of the social significance and importance of dignity and suggest that older age may threaten dignity by structuring and limiting the opportunities for participation and/or social recognition. Micro-sociological research has shown how older people negotiate their identity, in the face of its erosion by the aging body and disability and the domination of health and social care workers. These theoretical approaches inform the study presented here, which explores the meaning and experience of dignity for older people in their daily lives. Older people's accounts were elicited through a series of focus groups with participants living in England and Wales. Participants were selected according to predefined criteria to represent a range of different socio-economic and ethnic backgrounds, levels of fitness, and home circumstances. Personal identity and autonomy were the aspects of dignity most meaningful to the participants, and discussions tended to focus mainly on when personal identity and autonomy were threatened or violated in the context of the provision of health and social care. The authors discuss the extent to which older people's discourse on dignity resonates with the theoretical discourse.

Some causal limitations of pharmacogenetic concepts.

Pharmacogenetics and pharmacogenomics are related facets of cutting edge therapeutic research in a field that relates pharmacological properties to the genetic characteristics of human beings. An optimistic interpretation suggests that "One-Size-Fits-All" therapeutics, whose effects can only be predicted in probabilistic terms, will give way eventually to individual tailor-made therapies with entirely predictable properties in each patient. Yet the concept of anticipating individual pharmacotherapeutic response appears to disregard some of the fundamental limitations of causal understanding in the biological world of structure-action relationships. It is not simply a problem of confronting complexity - which might be overcome in time with advances in biotechnology and computing power - but the inescapable paradox of the genetic characteristics of individuals within the human species. The aleatory process of evolution ensures that with the exception of monozygotic twins, every human being is genetically unique. At the same time there appears to be more in common than divides. Pharmacogenomics provides a climate in which to explore and better understand the variable causal relationships between genetic element, protein and therapeutic or toxic actions, but can only do so in abstraction. Thus predictive power may be enhanced but is ultimately constrained by insuperable probabilistic considerations.

The expert patient: valid recognition or false hope?

The United Kingdom Department of Health initiative on "The Expert Patient" (2001) reflects recent trends in political philosophy, ethics and health services research. The overall objective of the initiative is to encourage patients, particularly those suffering from chronic conditions to become more actively involved in decisions concerning their treatment. In doing so there would be (perhaps) an expectation of better patient compliance and (arguably) a resultant improvement in quality of life. Despite these anticipated beneficial influences on health outcomes, there may be a danger that such initiatives are being carried along by the general swell of enthusiasm for recognising and facilitating the claims of disadvantaged or discriminated against groups. What more attractive than that patients should be "liberated" from what might be seen as the oppression of medical paternalism? To a great extent the potential for success of the Expert Patient venture turns on:(a) whether and to what extent a patient can be considered truly to be an expert and (b) full acceptance by the medical and heath care professions of allowing patients a more equitable and positive role. Whilst clearly the patient is an expert in the hermeneutic sense - it is they and they alone who experience their illness - there is nevertheless a risk of confusing experience with expertise. Experience limited to an individual does not of itself give rise to the generalisations that underlie reliable clinical treatment. Neither do the vast majority of patients possess the physiological and pharmacological knowledge to fully appreciate the biological nature of their illness nor the basis, risks or limitations of therapeutic measures. Might the notion of "The Expert Patient" as informed co-decision maker become a well-meaning but rather vacuous aspiration similar to that of informed consent? Even worse, could patient "empowerment" have a deleterious effect? The paper reviews some of the major issues and concludes that the expert patient initiative could have benefits for both patients and health professionals if operated on the basis of concordance: an informed collaborative alliance that optimises the potential benefits of medical care.

The basis and relevance of emotional dignity.

The paper is a preliminary examination of the origin and role of psychological perception or "feeling" of dignity in human beings. Following Ayala's naturalistic account of morality, a sense of emotional dignity is seen as an outcome of processes of natural selection, cultural evolution, and above all a need for social inclusion. It is suggested that the existence of emotional dignity as part of a human species-related continuum provides an explanation of why we treat those in a persistent vegetative state, the severely and hopelessly mentally impaired, the senile demented, cadavers and archaeological remains with dignity and respect. For older Europeans, dissonance between physical and mental abilities, unfamiliarity with social and cultural changes and relative proximity to death may influence their emotional dignity and hence vulnerability.