IX.

Current Issues in Medicine

A.

Medical Ethics

New medical, reproductive, and genetic technology in the second half of the 20th century led to increased concern about moral issues in medical treatment and research. By the 1990s, medical ethics, or bioethics, emerged as a recognized discipline that involved physicians, nurses, attorneys, theologians, philosophers, and sociologists.

Many bioethics issues involve the possible misuse of genetic engineering technology. The Human Genome Project led to identification of genes that raise an individual's risk of developing cancer, heart disease, mental illness, alcoholism, violent behavior, and other conditions. Tests to detect some of these disease-susceptibility genes became available in the 1990s.

These discoveries led to debate over whether genetic tests should be performed and how the results should be used. Should parents use such tests to screen their unborn infants? If a fetus tested positive, should it be aborted? If a woman tested positive for a breast cancer susceptibility gene, should the information be made available to insurance companies? Do insurers have a right to deny coverage to people with a genetic high risk for serious diseases? Do employers have a right to demand genetic screening tests before hiring people?

Genetic technology also offers the potential of eventually replacing defective genes with normal copies in human sperm and eggs. Some fear it will lead to mandatory eugenics programs, attempts to improve the hereditary traits of individuals or even entire races. Others argue that advances in genetic technology could eliminate defective genes and hereditary diseases from future generations.

An intense discussion about bioethics occurred in 1997 and 1998, after researchers in Scotland cloned the lamb, Dolly, from udder cells from an adult ewe. The experiment showed that it was possible to clone, or produce an exact genetic copy, of an adult mammal. Medical ethicists debate whether cloning of human beings should be permitted, as well as the potential effects on society.

Although abortion became legal in the United States in 1973, it still causes heated debate over the rights of the fetus and the pregnant woman, as well as the question of when a fetus becomes a human being. The availability of RU-486, also known as mifepristone, an inexpensive drug that induces abortion, led to concern that more people would use abortion for birth control. Ethical discussions centered on whether tissue from aborted fetuses should be used in medical research, treatment of disease, and organ transplants.

The right of terminally ill people to receive assistance in dying raised other ethical dilemmas. Physician-assisted suicide came to national attention largely through the efforts of Jack Kevorkian, a Michigan physician who helps people with terminal illnesses commit suicide. Opponents claim it is unethical for physicians to help patients commit suicide. Supporters counter that terminally ill patients have a right to determine the time and manner of their death. While the U.S. Supreme Court in 1997 ruled that states can ban physician-assisted suicide, that same year Oregon voters rejected an effort to repeal their law, the nation's first to legalize physician-assisted suicide.

B.

Preventive Medicine

In the 1960s and 1970s, physicians and medical educators began to recognize a basic flaw in the health care system. Medicine traditionally was concerned with treating disease after symptoms appeared, resulting in treatment that was often very expensive. About 600,000 coronary bypass operations were performed annually in the United States in the 1990s, at a cost of $44,000 each. Medical officials recognized the advantage of preventing disease in the first place, rather than just treating it.

Medical schools began teaching students the importance of disease prevention. Some physicians specialized in a new field, preventive medicine, which emphasized keeping patients healthy. Practicing physicians spent more time counseling patients about smoking, excessive drinking, and other unhealthy practices. They did so by encouraging patients to avoid risk factors for disease; take periodic screening tests that detect disease early; and treat high blood pressure.

Yet by the late 1990s, many people still failed to use preventive services. Studies in 1997 estimated that 30,000 deaths per year could have been prevented if more people were immunized against influenza, pneumococcal pneumonia, and hepatitis B. Likewise, smoking, the leading preventable cause of death in the industrialized world, causes more than 4 million deaths worldwide each year.

Another dramatic change in medicine involved the idea that individuals have an important role in preventing diseases caused by an unhealthy lifestyle. Health care consumers grew more knowledgeable about medicine. Medical pages became a regular feature of major newspapers, news magazines, and television news programs. Some people subscribed to magazines and newsletters devoted entirely to health. Laypeople consulted books, such as the Physician's Desk Reference and The Merck Manual, once used only by professionals. They also tapped health information available on the Internet's World Wide Web (WWW). With this knowledge, consumers sought to become partners with their physicians in deciding the best ways of preventing, diagnosing, and treating disease.

C.

Nontraditional Medical Practices

A resurgence of interest developed in the 1990s in medical treatments not fully accepted by conventional medicine or biomedicine, which requires stringent scientific proof of safety and effectiveness before accepting a treatment. Such evidence is lacking for many approaches used in the medical systems and treatments known as alternative medicine in the United States. In Europe, these same approaches often are called complementary medicine. Growing public interest in nontraditional treatments led the NIH to open the National Center for Complementary and Alternative Medicine (formerly the Office of Alternative Medicine) in 1992, which encourages research on alternative medicine. The number of Americans using an alternative therapy rose from 33 percent in 1990 to more than 42 percent in 1997.

Alternative medicine emphasizes improving the quality of life for people with chronic illness; disease prevention; and treatments for conditions that conventional medicine cannot adequately control, such as arthritis, chronic pain, allergies, cancer, heart disease, and depression. A cornerstone of alternative medicine is the idea that the mind influences the health of the body.

Alternative medical systems include chiropractic, holistic medicine, and homeopathy. Chiropractors treat disease with spinal manipulation, massage, diet, and many other techniques. Holistic healers emphasize treatment of the whole person, including body, mind, emotions, spirit, and interactions with the family and environment. Homeopathic healers use substances that cause the very symptoms being treated. When treating a headache or nausea, for example, homeopathic healers administer herbs that in large doses cause headache or nausea. But they use very small doses that cause the patient no discomfort.

Specific alternative medical treatments include aromatherapy, inhaling oils from aromatic plants; massage techniques, including Rolfing and reflexology; biofeedback; iridology, in which the eye is used to diagnose certain diseases; and acupuncture. Some approaches, including chiropractic manipulation and acupuncture, have gained greater acceptance in conventional medicine. Some conventional biomedical studies have concluded that chiropractic manipulation is effective for low-back pain. A 1997 NIH report gave acupuncture limited endorsement for certain medical uses.

Organizations that educate the public about health fraud and quackery expressed concern about growing interest in some alternative medicine treatments. They emphasized the importance of receiving a conventional medical diagnosis, and exploring standard treatment options, before turning to alternative medicine.

D.

Cost of Medical Care

The United States spends more on health care than any other country in the world. Spending in 1998 averaged $4,094 per person, compared to $2,689 in 1990, $1,052 in 1980, $341 in 1970, and $141 in 1960. The only countries that approached the United States in per capita spending were Switzerland ($2,412), Germany ($2,222), Luxembourg ($2,206), and Canada ($2,002). In the United States, spending on health care exceeded $1.1 trillion in 1998, up from $699.4 billion in 1990, $247.3 in 1980, $73.2 in 1970, and $26.9 billion in 1960.

Yet millions of Americans still do not have adequate access to health care because they lack insurance coverage. An estimated 44.2 million people had no health insurance in 1998. Access is a greater problem in the United States because most other industrialized countries have national health insurance systems that cover medical expenses. Since the 1960s, the United States Congress established and expanded programs to improve access to care. Medicare, the major program, covered about 38 million people over age 65 and people with disabilities in 1997. Another was Medicaid, a federal-state program that covers low-income people. During the 1990s, Congress considered and rejected proposals to establish a national health insurance system or extend government health care benefits to more people. The high costs of such a program were among the reasons for rejection.