 Hi, I'm Christine Mitchell from the Center for Bioethics at Harvard Medical School. With me today is Marcia Angel, who is a physician, world-renowned author. She's also the first and only woman editor-in-chief of the New England Journal of Medicine. Marcia, for many years, organized and led a faculty seminar on medical ethics at Harvard Medical School, and she's also written on a wide variety of topics in medical ethics, including a book, The Truth About Drug Companies, and another one entitled Science on Trial, and hundreds of articles on topics ranging from the American health care system and health care reform, conflicts of interest in academic publishing, physician-assisted dying, silicone breast implants in the 90s, alternative and unregulated medicine, research ethics in developing countries, and even about the role of women in medicine. We won't be able to talk about all of those things today, of course, but I would like to talk with you about a few of them and see what you're thinking today. You have for a long time been a staunch critic of the pharmaceutical industry's marketing practices, especially direct to consumer advertising and subsidizing physicians continuing education and consulting fees, and yet it still seems impossible to get pharmaceutical money out of medicine. Are you still as concerned? Have we made any progress in some ways? It seems to me to be getting worse. Where are we headed? I think you're right. I think it is getting worse. The pharmaceutical industry is now seeing faculty at prestigious medical centers as their salespeople, hiring them, paying them vast amounts of money with various labels. Subsidizing their research? Well, yes, but subsidizing the research is one thing, but there are all kinds of strings attached and all kinds of other financial ties, speakers, bureaus, speaking and continuing medical education courses. In one way or another, they're funneling vast amounts of money to academic physicians. We have done a better job of getting it out of residents' education, at least when I first came. With industry money, we would buy residents' lunches, and now we don't do that anymore. In some ways, we've created this big divide where a number of people think about the pharmaceutical and medical device companies as the big bad wolf, and they think of us as the academics in the ivory towers, and there seems to be this big gulf between us, which shouldn't be the natural outcome of trying to keep some of that money out of medicine in a way that corrupts it. Is there some way that we can get back to a place of conversation where we can understand one another without the corrupting influence of industry money? I wish there were a gulf. My problem is that there is not a gulf, and our missions are quite different. They are investor-owned companies whose mission is to increase the value of their shareholder stock. That is their mission, to sell drugs anyway that's legal. Many of them have done it in illegal ways as well, and that is not the mission of academic medical centers. The industry likes to talk about a public-private partnership. They want it to sound as though we have the same mission, but we really don't. Their mission is to sell profitable drugs, not necessarily good drugs, valuable drugs, and that's what they do. They're doing that increasingly by co-opting the faculty at academic medical centers with all this happy talk about we're in the same business. We are not in the same business. We know they have big research ethics enterprises that are supposed to provide for compliance and oversight of research. We've wondered about how best to engage with them in a way that has people doing research ethics within industry, not just within academia, benefiting from thinking about research ethics in a neutral place, in a neutral way. They know what they're supposed to do. I can think of a single large drug company that has not been guilty of fraud, and most of them have actually pleaded guilty and paid hundreds of millions, billions even, of dollars, which to them is just the cost of doing business, and then they just do the same thing over again. They know what they're supposed to do. They know what the law is. This is a very kind of a fine sort of a word to apply to what goes on in the pharmaceutical industry. It sounds good to us, but they know how to behave. They just don't find it profitable to behave that way. What will it take to fix this problem? Well, I think it's going to take some tight regulation. The drug companies get away with a lot. The government gives them government-granted patents. It gives them all kinds of tax breaks. And most important, it allows them access to NIH-funded research carried out at medical schools and teaching hospitals. And then the medical schools and teaching hospitals patent it, license it exclusively to drug companies who then charge whatever they want for drugs that they had no hand in discovering. And in fact, if you look at the evidence, most innovative drugs are the result of NIH-funded research. And yet they take it over, they buy the drugs by paying some royalties to the medical centers and to the hospitals, not all that much, whom they treat as junior partners, and then they go on and put a price tag on it, sometimes tens of thousands of dollars a year. So we don't have to give them all the goodies that we as taxpayers give them. We can say, no, you may not do, me too, drugs have to be compared with other drugs, not just with placebo's, but with effective drugs. We're not going to give you tax breaks unless you put some money into, say, new antibiotics. There can be a lot of quid pro quos because what we give them is so valuable, they wouldn't be in business if it weren't for the NIH. They wouldn't be able to be in business. You know, really what you're saying is there are things to bargain with and it isn't necessary to reign. Oh dear, big time. Big time there are things to bargain with. You have to get the U.S. Congress, though, off of their payroll. That's important. Yeah, there is that point. Speaking of the United States Congress, but on another topic, a lot has been done since you first started writing about health care reform and fixing American medicine. You've been a longtime supporter of eliminating private health insurance and moving to single payer health care. Now that the Accountable Care Act is five years old, Obamacare is in place and had a number of challenges, but it still seems to me that the doctor is, to use your words, a double agent. Is it getting better? No. The ACA, good people, my husband, among others, believed, okay, the glass is half full here. This is better than nothing. We can make reforms as we go along. And there were other people, and I was one, who felt, no, that the glass is more than half empty and that the problem with Obamacare is as it unravels, which it is doing, people will say, oh, I guess we can't afford universal health care. We tried that third rail end of story, that people would draw the wrong lesson instead of saying this was the wrong reform. They would say, well, we're never going to do that again. I don't know, still, which of those two things will happen, but I know that it cannot continue the way it's going now. The costs are rising too fast, and what the insurers are doing is what you might expect them to do to shrink the benefit package. What employees are doing is passing along more of the premiums for their employees to pay out of pocket. It is unraveling because it's unaffordable. And the reason it's unaffordable is that Obama made the critical mistake of continuing to have the private health insurance industry involved, and number two, to continue to allow health care to be delivered by profit-oriented providers. And this includes medical specialists, but it also is standalone clinics, imaging centers. So those two things, having the investor-owned private insurance industry, the linchpin of the whole thing, in fact, what Obamacare does is to hand them millions of new customers. They're thrilled with it. They're required to take. Right. But they're thrilled with it. And to have the profit-oriented delivery system is a recipe for inflation, and that is exactly what we're seeing. So is the only reasonable alternative in your mind going to a government-supported public system? Yes, we do have a government-supported Medicare. And the problem with Medicare is it still has the profit-oriented delivery system and uses the same delivery system as the private insurance companies. But yes, that's the way to go, to have Medicare for all and have it in a nonprofit system. It is the only way. It is the absolutely only way to provide universal care at a cost that we can afford and will continue to be able to afford that's not inflationary. We think the prospect side that we'll get there in the reasonable future. But what if there is, Christine? I'm kind of a card-carrying pessimist, but I think it might happen. I think it could happen. And do you know how I think it might happen? Obamacare, not many people are aware of this, but Obamacare will allow the private insurance to charge older people, by which I mean people in their late 50s, early 60s, three times as much as younger people. And these are precisely the people who won't be able to afford it. They're starting to get chronic illnesses. Some of them vote. And they vote? Yes. You're absolutely right. They vote. When they think about, hey, maybe Medicare could start at 55 instead of 65, they think that's a pretty good deal, and they vote. So I think that the idea of dropping the qualifying age for Medicare one decade at a time has legs. I really think that could happen. I hope in my lifetime. That's optimistic. I think that would be a little... Marcia, you have been a courageous and provocative thought leader in medical ethics. At the same time, you've been married and raised a family while making a major impact on the policies and practices of medicine. You've acknowledged that women often do more than their share when it comes to teaching, mentoring, and committee work, often foregoing the kind of research and writing that advances their careers much more effectively. And yet at the same time, you've done this yourself, pushed against and perhaps it would be fair to say shattered that glass ceiling. How did you do it? Well, I did it at a time. In every woman carved her own path, nobody could follow really a straight path. There was no way to get there from here. So I kind of followed it. I think it was Mao Tse-tung in China who said seize the moment. And for me, it was a matter of seizing the moment. And the result was a terribly crooked path in which I had to work very hard while keeping my open eye open for the moment I could seize at that time. I think that, and at that time too, this was in the 60s, 70s, even the 80s. And in those times, particularly after the 70s, when women started to come into medicine in big numbers, what you saw was more and more responsibility being put on their shoulders because every committee needed a woman on it. Every committee, all teaching, which was never valued. What was valued was publications. Women were celebrated as teachers. Women were great helpers of the men who were climbing to the top by publishing because you just counted their publications. So women were everywhere doing the work that was not heavily rewarded, in addition to which at home, even in the best marriages with the most thoughtful husbands, husbands thought that they were helping her. She was never helping him. So the woman had to have the executive responsibilities at home. He might go and buy the child a pair of shoes, but she had to say, hey, these shoes are too short time for another pair of shoes. So they were helping, but they weren't organizing and they certainly weren't carrying out the executive functions. So this was a very hard time for women. I think it's better now. You could probably tell me, but one of the reasons it's better is that men at home are now seeing themselves as primary parents, as co-parents. And I see that in my sons-in-law. It's quite wonderful, really. She doesn't have to do all the executive stuff. My sons-in-law do executive stuff, too. So I hope that things are better. I still think that there are glass ceilings that have to be broken. We haven't had a woman president in the United States yet and there are some similar glass ceilings in medicine. But I think we're coming along. You've also written about some ways of leveling the playing field, about changing criteria for promotion and tenure, in order to acknowledge the kinds of contributions that, typically, women tend to make in medicine and academia. Are there ways that it's possible to level the extent to which various components of a career count in moving ahead? Absolutely. Absolutely, Christine. I think that's a very good point for you to bring up. I think it was way back in the early 80s, I wrote a paper saying that instead of counting Professor Gushmugelwitz's 16 publications, let's look at his best publications and let's limit them. So I propose for assistant professor, as I recall, that the candidates say, these are my three best publications and you look at those. Or for associate professor five or for full professor 10. And the candidate decides what should be looked at. This got a lot of attention, including at Harvard. And I think that they did put some limits, but they didn't say we don't want to see the others. So they would still send the list of the 600. And the candidate would say, among my 600 publications, these are my 10 best, which kind of offset the whole point of the exercise. So I think we really should look at the publications. I mean, one advantage would be people would actually read them, promotions committees. And the other thing is we ought to reward teaching. That is what a medical school is. I mean, the primary function is to teach medical students, to teach future doctors. And that should be rewarded as much as research. So yeah, there are things to be done. You've also done a lot of work on physician-assisted dying and still are interested in and working on that topic, including the referendum in Massachusetts, but also speaking all over the country and in other countries about this. Can you give us just a short definition of what you mean by that, since the term is now sort of bland and sanitized? It used to be call physician-assisted suicide. It's been legal in Oregon since, I think, practice since 1997, a long, long time. And it is now legal in four other states. And the law says that this is only for people who are within six months, likely nobody can know for sure, of dying of an incurable disease and who ask to have their physicians and their life if and when the patient decides, usually with barbiturates, with a lethal medication, so that they don't have to keep soldering on and suffering and suffering and suffering with each day getting worse than the one before. So that's what it is. It has two essential features, that it is the patient's decision and nobody else's, not the family, not the doctor. And there are all kinds of ways to make sure that it is voluntary, that it is the patient's decision, among which the patient actually has to swallow the medication. It can't be injected. So it has to be the patient's decision and it has to be in a patient who will die anyway, likely within six months. So that's quite. And I'm wondering, as you wrote about this, you talked, there's a lot of controversy within the medical profession about this. And you've implied, if not said outright, that physicians might be an obstacle to making change in the area of end-of-life care for patients and physician-assisted dying. Do you still think that's the case, or is there are physicians themselves beginning to move on this? I think they're moving on this. I should say that this is one area in which I'm even more optimistic than I am about Medicare for all. Because on this issue, there's no money. It isn't as though insurance companies are gonna fight against you or the pharmaceutical industry is gonna fight against you. There's really no money at stake here. It's entirely, entirely a medical and ethical issue. And whenever you get money out of the way, you can look at something much more clearly. And I see a huge move. We now have five states where it's legal. All of Canada, it's legal. It won't be implemented for another year, but it is now legal in all of Canada and in some countries in Europe. I think it's just a matter of time before one state after another okays it. And in fact, the referendum in Massachusetts that failed narrowly in 2012, I think that that were in the ballot now it would pass. So you've worked for many years at the New England Journal of Medicine and also overlapping, but then a lot of years at the Department of Global Health and Social Medicine and the Division of Medical Ethics at Harvard Medical School and now the Center for Bioethics doing work in medical ethics and leading a faculty seminar series. Before that, you were editor-in-chief of a huge world-renowned New England Journal of Medicine. Were those similar? Were they very different? They were remarkably similar in a certain way. No, I was at the New England Journal of Medicine for 21 years. And starting as an executive editor? I started as assistant deputy editor. And then I went to deputy editor and then senior deputy editor. And then I did, you know, work at my time. One step at a time, that's right. And I love that job. I love the job for several reasons. I love editing. I think I'm pretty good at it. And I love the process of trying to make author's work as good as it could be. I also love the pace of it. Came out in the New England Journal of Medicine, comes out every week. There's no week off for Christmas or 4th of July. So every week I could see whether I'd done a good job or not the week before. I love the fact that I had an eagle's eye view of everything that was happening in medicine. Not that I'm expert in every specialty or everything that's happening, but one way or another, I would hear about what was happening, usually through submissions, through authors. So I love knowing that I knew what was going on in medicine. And I love the bully pulpit. I could write editorials. And I wrote, I don't know how many, but probably a couple of hundred editorials to talk about issues that I thought mattered in medicine. And these were usually ethical issues. I started at the Department of Global Health and Social Medicine a long time before there was such a thing. I think that was in 1990 as a senior lecturer in what was then called the Department of Social Medicine. I think Leon Eisenberg appointed me, that's right. I don't even think there was a division of medical ethics, let alone a center. I mean, a remarkable center for bioethics. So that's where I started. When I retired from the New England Journal of Medicine in 2000, I had already started to do some of the ethics seminars, the faculty seminars, but I began to think more about those seminars and spend more time on them. Well, the first thing I did after I retired from the New England Journal of Medicine was to take a nap every day for two months. But once I had caught up on my sleep, then I started to think more about the faculty seminars. And in a sense, it had some of the same things because what I was able to do, there weren't submissions. I had to go out and find these people, but I got some of the best minds in American medicine and I brought them in and then I could listen to them. And ask them hard questions. And that was a little bit like editing in the sense that I would push them. Well, what about this? What about that? And the attendees would push them too. So they were forced to defend their arguments just as people who submitted manuscripts were forced to defend their arguments. And I got to sit there and listen to the whole thing. I began to have subjects for the whole year when healthcare reform came up. I had a whole year's subject every month. Somebody was speaking on some aspect of that. So that had some of the same pleasures. One of the interesting things for me too is some of the people now, including the head of the Center for Bioethics, Bob Trug, had written for the New England Journal of Medicine back when I was handling those manuscripts. I mean, he was a shy young man. And I think, and I was in charge of these unsolicited opinion pieces. And I think I published his first back in the late 1980s, Dan Brock. There were a lot of people who then became my colleagues and my boss whose manuscripts I had in a way discovered. And I discovered them because they did and they still do have a way of going to a center subject with an original novel point of view and arguing it intelligently. So there are connections between my two lives. I do want to thank you for sitting down and talking a little bit about a few of the things. Christine, it's been a great pleasure. I really enjoyed it. Thank you, Marcia.