Live longer, live better

5 Sep 2022

New active ingredients, automated surgery or personalized cancer therapy - medical research is constantly producing innovations. But not all of them make people healthier. How do we define medical progress?

One of the greatest success stories in medical history began with a handwritten note: “If cells can form proteins from the mRNA inserted in them, it would be possible to use RNA like a drug”, the young doctoral candidate Robert Malone scribbled in his laboratory journal at the Salk Institute for Biological Studies in La Jolla, California, in 1988. In an earlier experiment, Malone had mixed mRNA – molecular blueprints for proteins – with fat droplets and then injected them into human cells. The latter absorbed the mRNA and began to fabricate proteins in accordance with the given template.

More than 30 years later, when a virus unhinged the world in the twinkling of an eye, Malone’s discovery suddenly became world famous. At break-neck speed, researchers used the mRNA technology to develop vaccines to combat the pathogen. The vaccines were administered billions of times over and were instrumental in getting the coronavirus pandemic under control. Yet while the mRNA method is a classic example of medical progress, not every new drug or treatment immediately proves its benefits to human health on such a scale. So, how do we find out whether we are dealing with genuine medical progress? Can generally valid criteria be applied to answer this question?

Showcase for medical progress

Development of an mRNA vaccine: The picture shows vaccine production in Berlin, 2022.

© Ute Graboswsky/Photothek/Picture Alliance

Muster des Fortschritts

Read the new issue of our research magazine EINSICHTEN/INSIGHTS at | © LMU

One person looking for answers in a professional capacity is Georg Marckmann, Professor of Medical Ethics at the Institute for Ethics, History and Theory of Medicine at LMU Munich. Medical progress must be measurable especially in terms of “the value it adds for patients’ health”, he says. Does a novel therapeutic approach let people live longer or better, for instance? If such questions can be answered in the affirmative, the ethics expert reasons, then innovations can be deemed to be progress.

An independent body evaluating countless medical products

However, affirmative answers are rarely as resounding as in the case of mRNA vaccines. Moreover, financial interests undoubtedly play at least as important a role in medical development as health concerns. Marckmann therefore believes it is important for independent bodies to keep an eye on new methods of treatment, but also on the countless medical products that seem to be flooding the market. In Germany, this is done by the Institute for Quality and Efficiency in Healthcare (IQWiG), which says it examines “the benefits and harms of medical interventions for patients”. In the form of scientific reports and readily comprehensible healthcare information, IQWiG provides an overview of the advantages and drawbacks of medical examination and treatment methods. Its findings can at least serve as a plumbline by which to assess the value – and hence the potential progress – that newly developed drugs and diagnostic or therapeutic methods add for human health.

Prof. Dr. med. Georg Marckmann

Value added

Medical progress must be measurable in terms of the “value it adds for patients’ health,” says Georg Marckmann.

© Stephan Höck / LMU

The price for the patient

Yet even if independent bodies and scientific studies attest to the health benefits of this or that product or method, it still does not always make sense to use them. Imagine the following scenario: A person seriously ill with cancer is in the intensive care unit, under artificial respiration from a modern device and being treated with new drugs. “In principle, I think it is right for medicine to do all it can to save lives,” Marckmann says. Sometimes, however, the patient pays (too) high a price – because of serious side-effects, for example, or because of a deteriorating quality of life. This is where medicine encounters a fundamental problem: “There are no generally valid standards that define the ‘right’ ratio of lifespan to quality of life,” the professor states. Ultimately, sufferers should always decide this matter for themselves. What medicine is capable of doing can only ever be an “offer to people”, he adds; and an offer can be accepted or rejected.

For this reason, the ethics expert believes that great importance should be attached to “respecting patient autonomy” in medical practice. For him, medical progress is not just about developing effective diagnostic or therapeutic methods, but also about providing treatment in line with the patient’s individual wishes. It is about “patient-centered medicine”, in other words, where the principles of modern, high-performance medicine are not the sole factor on which decisions about therapeutic interventions are based. Sometimes, Marckmann argues, progress means doing less.

When medicine becomes too expensive

To allow patients’ wishes to be taken into account even when they are no longer able to communicate, Marckmann’s working group is developing programs to plan therapeutic decisions in advance. The questions are weighty and often not easy to answer: Do you want to be resuscitated after a stroke? Should life support systems be used in spite of serious brain damage? The expert believes that people should not be left alone with such issues. On the contrary, they should receive professional support in making treatment decisions in advance. He and his team have now at least got health insurers to pay for professional support with the preparation of advance directives. And for the professor, this represents “ethical progress in medicine”. If they had been asked beforehand, he notes, many people would forgo. life-sustaining interventions in severe health crises that result in lasting impairments.

Marckmann points out that, since healthcare has become ever more expensive, it must be made more cost-effective, which in turn changes the whole equation. Funding is already short wherever one cares to look, and demographic change will make this situation even worse as the number of gainfully employed persons financing the health insurance system dwindles. At the same time, the proportion of retired people – who need the majority of medical services – is rising. “In the future, we will have to look much more closely at the spending,” Marckmann exhorts. For him, another aspect of medical progress would be to place healthcare funding on a more sustainable basis.

Health care has become more and more expensive - always to the benefit of patients?

© pictue alliance / Christian Charisius / dpa

High level of medical care

Wherever medical interventions are to be made, therefore, he always advocates a cost-effectiveness analysis. Some high-end medical methods in particular are very costly, while the value they add to a patient’s health may be minor. “In situations like this, we must always weigh carefully whether it is justifiable to administer such interventions,” he says. That is not to say that rare or ‘expensive’ diseases should not be investigated or treated. On the contrary: “We must organize healthcare in such a way that everyone has access to effective treatments.” That, however, will work only if we forgo cost-intensive interventions where they are not necessary.

The same applies for certain expensive investments. Germany already enjoys a very high standard of medical care, leading economists to speak of “diminishing marginal utility”. This simply means that each successive step of progress becomes comparatively smaller but must be purchased at ever greater cost. That is certainly true of innovations in medical products and technology.

That said, Marckmann sees an urgent need for innovation in processes and organizational methods. The aim, he says, is to make care more efficient and more patient-centered at the same time. That can mean avoiding multiple examinations – first by a specialist and then again at the hospital, for example. A digital infrastructure is needed to establish better connectivity across the different stages of care. But it would also help doctors to better coordinate the treatment of a given individual. Another advantage is that more precise treatment would save on resources and cut costs. The fact that digitalization in healthcare has been badly neglected in Germany is another thing that came to light during the pandemic. “This is one area where there is still plenty room for medical progress.”

Life expectancy has increased by more than 30 years since 1900

But it is not the only such area. As soon as agreement is reached that the overriding goal of medical progress is to advance public health, entirely different factors come into play: While average life expectancy has increased by more than 30 years over the past century, less than half of this gain is attributable to improvements in medical care. Rather, issues such as hygiene, nutrition, education and social welfare have also played a part. “If we want to improve public health, we must invest much more in these non-medical determinants,” is Marckmann’s advice.

The effect of neglecting such determinants is evident from the socioeconomic health divide in Germany: Poor people and people in precarious employment are worse affected by chronic conditions such as coronary heart disease, diabetes and depression. The same correlation was observable with Covid-19. Ultimately, poorer health affects life expectancy: Men who earn less than 60 percent of the mean German income live for nine years less on average than men who earn 1.5 times the national mean wage.

Marckmann is thus convinced that, to improve healthcare for all, greater social equity is needed in society at both the national and global levels. He sees it as blatantly apparent that the inequitable distribution of wealth around the planet is the crucial factor in ensuring that not everyone experiences medical progress to the same extent. There is no shortage of solution paths to change this situation, he notes: better working conditions, higher wages, access to education and so on. “A higher standard of education leads to healthier behaviors, better jobs, higher incomes and more contributions to health insurance,” Marckmann continues his argument, describing the outcome as a “win-win situation”.

What are the primary healthcare needs?

Germany can at least claim that every citizen has health insurance and is entitled to comparatively good medical care. In lots of other countries, this is not the case. In the USA, for example, many people from low-income households have no health insurance and no access to the medical care network. Yet even in Germany, poorer people receive poorer medical care – in part because of organizational obstacles, language barriers and a lack of knowledge about treatment options. Here again, a better education could improve the situation.

“We urgently need a societal discourse on how we should set healthcare priorities in the future,” Marckmann contends. What are primary healthcare needs? How can we provide people with better healthcare for less money? Valid answers to such questions could make medicine – or care for people’s health, to be precise – genuinely progressive. Instead of exclusively backing innovative drugs and sophisticated technologies, Marckmann appeals for investment in creating better conditions in society for a long and healthy life. “What we have now is ‘repair medicine’ that focuses on deficits,” he says. “But we also need medicine that promotes health.” This includes the resources that everyone needs to avoid diseases and stay in good health.

Changing the direction of medicine in this way obviously does not imply doing without any medical product innovation in the future. The pandemic showed us very vividly how important such innovations can be in times of crisis. However, what applies to the mRNA method does not necessarily apply to the same extent to every medical innovation. On the subject of mRNA: Robert Malone immediately recognized that the outcome of his experiment could lead to significant medical progress. How else can one explain the fact that he signed and dated his entry and, to be on the safe side, also had it countersigned by a colleague?
Janosch Deeg

Georg Marckmann is Professor of Medical ethics and Director of the Institute for Ethics, History and Theory of Medicine at LMU Munich. Born in 1966, Marckmann studied medicine and philosophy at the University of Tübingen and public health at Harvard University. He earned his professorship in medical ethics at Tübingen’s Institute of Ethics and History of Medicine before moving to Munich in 2010. Since 2012, he has served as President of the German Academy of Ethics in Medicine.

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