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Contents - JLME - 2011 Volume 39: 2
Table of Contents
  1. Table Of Contents
Letter From The Editor
  1. Letter From The Editor
Introduction
  1. Introduction: Caring for the Seriously Ill: Cost and Public Policy
Symposium Articles
  1. End-of-Life Care: A Philosophical or Management Problem?
  2. The Ethical Implications of Health Spending: Death and Other Expensive Conditions
  3. Care, Compassion, or Cost: Redefining the Basis of Treatment in Ethics and Law
  4. Health Care Accessibility for Chronic Illness Management and End-of-Life Care: A View from Rural America
  5. Just Caring: Health Care Rationing, Terminal Illness, and the Medically Least Well Off
  6. Futility, Autonomy, and Cost in End-of-Life Care
  7. Making the Case for Talking to Patients about the Costs of End-of-Life Care
  8. Costs and End-of-Life Care in the NICU: Lessons for the MICU?
  9. End-of-Life Decision Making across Cultures
  10. The Value of Life at the End of Life: A Critical Assessment of Hope and Other Factors
  11. In the Business of Dying: Questioning the Commercialization of Hospice
Independent Articles
  1. Fetal Pain, Abortion, Viability, and the Constitution
  2. A Living Wage for Research Subjects
  3. Multi-Professional Recommendations for Access and Utilization of Critical Care Services: Towards Consistency in Practice and Ethical Decision-Making Processes
  4. Testing Public Health Ethics: Why the CDC's HIV Screening Recommendations May Violate the Least Infringement Principle
  5. Reining In the Pharmacological Enhancement Train: We Should Remain Vigilant about Regulatory Standards for Prescribing Controlled Substances
Columns
  1. Currents in Contemporary Bioethics: Constitutional Right to Informational Health Privacy in Critical Condition
  2. Teaching Health Law: Personal Reflections on Teaching Health Law in a School of Public Health
  3. Recent Developments in Health Law: Essential Medicines: Why International Price Discrimination May Increasingly Be the Wrong Solution to a Global Drug Problem
Table of Contents
Table Of Contents
ASLME - [PDF] (Free Download)
THE JOURNAL OF LAW, MEDICINE & ETHICS CONTENTS VOLUME 39:2 Summer 2011 Symposium Articles Introduction Thaddeus M. Pope, Robert M. Arnold, and Amber E. Barnato End-of-Life Care: A Philosophical or Management Problem? Daniel Callahan End-of-life care became an important issue in the late 1960s and early 1970s. It was in great part driven by complaints about the care of the dying: lack of patient autonomy, indifferent or insensitive physicians, and inadequate pain control. The main task of those who worked to improve the situation centered on changing each of those variables, assuming that would do the job. But it has worked to a moderate extent only and the problem is not fully solved. The main omission has been a failure to confront the medical enterprise itself, which believes in endless progress and conducts a war against death. Only a change in those underlying values can bring about further significant change. The Ethical Implications of Health Spending: Death and Other Expensive Conditions Dan Crippen and Amber E. Barnato The cost of health care in the United States has important generational considerations whether analyzed at a point in time, or over many years. The budgets of governments contain important information about the funding of public services, including health care, and the intra- and inter-generational implications of both the inherent tradeoffs, and the particular means of funding the services. End-of-life expenditures, while a significant component of the cost of health care, are not the primary consideration in the ethical or moral questions raised.
Letter From the Editor
Letter From The Editor
ASLME - [PDF]

Thinking about and planning for the end of life is difficult even in the abstract, academic sense; it is even more so when it concerns a family member or loved one. That is why policy issues around the end of life have been and continue to be hot-button topics in the worlds of medicine, law, politics, and in our society at large. We need look no further than the recent, continuing debate about health care reform in the United States and the place that end-of-life care has within that reform to realize how quickly passions can be stirred on this subject. In this issue of the Journal of Law, Medicine & Ethics, Guest Editors Thaddeus Pope, Robert M. Arnold, and Amber E. Barnato examine what they call the "exponentially bigger profile" of end-of-life care as it has developed over the last few decades in American life. It is no coincidence, of course, that this profile has grown not only because of the public's natural interest in the subject but also because of more recent pressures to cut medical costs wherever possible.
Introductions
Introduction: Caring for the Seriously Ill: Cost and Public Policy
Thaddeus M. Pope, Robert M. Arnold, and Amber E. Barnato - [PDF]

The cost of end-of-life health care is currently the subject of enormous political, academic, and social debate. Sure, this was big news back in the early 1980s, when both Alan Greenspan and Governor Richard Lamm famously articulated the need to limit medical care of the elderly. But three decades later, in 2011, the cost of end-of-life health care has an exponentially bigger profile. President Obama has himself personally addressed the issue in the context of his own grandmother's treatment. And top federal policymakers have targeted end-of-life health care costs for reduction. Indeed, such reductions are proposed both to finance expanded insurance coverage and to preserve the country's fiscal stability and security. Furthermore, discussion of these issues was fueled by the recent (and related) plan to develop critical care triage protocols for pandemic influenza.
Symposium Articles
End-of-Life Care: A Philosophical or Management Problem?
Daniel Callahan - [PDF]

Early in 1970, just as we were organizing The Hastings Center, we had to decide which issues on a long menu of possibilities should receive our early attention. At the top of our list was end-of-life care. Complaints about care for the dying had mounted during the 1960s, fueled by technological progress in sustaining life, by too many patients abandoned by physicians as they lay dying, by a lack of patient choice on how their lives should end, and by woefully inadequate pain management. After a few years of study, the care of the dying seemed to admit of a solution: giving patients more choice by the use of living wills or appointment of a surrogate, improving the training of physicians to better deal with death and discussion with patients, and creating a hospice movement and greatly enhanced palliative care. But here we are four decades later, not quite back where we started, but much less far along than we had naively thought possible. While I have varied the titles a bit, I have written at least four articles over the decades that have simply reworked a persistent question on end-of-life care: why has it been so hard? I have chewed on that bone and so have many others. To be sure, progress has been made. Probably close to 25% of adult Americans have a living will and/or have appointed a surrogate. Over 900,000 of us die each year in the care of a hospice program. Palliative care is now a medical specialty and doctors receive a better education in communicating with patients.
The Ethical Implications of Health Spending: Death and Other Expensive Conditions
Dan Crippen and Amber E. Barnato - [PDF]

Overview: In this essay I ask the reader to consider the "end of life" as a life stage, rather than as a health state. At one end of the life course is childhood and at the other end is elderhood. The basic inter-generational social compact in most societies is that working adults take care of their children and their parents, and count on their children to do the same for them. In developed countries, these obligations are met in part through government programs, with taxpayers funding significant portions of education, health care, and income support. The financing of these public programs, in addition to other public services, involves ethically charged trade-offs. In the United States, public outlays on behalf of children and the elderly span roughly the same number of years, but with very different levels of spending. Cross-sectionally, transfers from workers (via taxes) go more to the elderly in the form of Medicare and Social Security income than to children in the form of public education and means-tested health insurance (e.g., Medicaid, SCHIP). Longitudinally, delayed "transfers" to these same children are manifest as better or worse economic conditions once the children become workers. If current workers, in addition to providing for the young and old through taxpayer-funded social programs, manage to save as well by reducing their own consumption of goods and services, then future generations are likely to be better off since these current savings are invested in capital which will allow the economy to grow (faster). In contrast, if individuals, institutions, or governments borrow for consumption today, then future generations are likely to be worse off since current consumption may reduce economic growth in the future and, in the case of public borrowing, additionally obligate future taxpayers to fund the cost of expenditures we make today.
Care, Compassion, or Cost: Redefining the Basis of Treatment in Ethics and Law
Tom Koch - [PDF]

Introduction: Early announcements of this special journal issue solicited authors interested in contributing articles on the subject of "costs at the end of life." Those who replied were then informed the title was being changed, on the basis of early subscriber interest (or, perhaps disinterest), in "rational end-of-life treatment." Because that seemed a still inadequate reflection of the authorial concerns of responding potential contributors, the editors again changed the title, two months later, to "Making Treatments More Rational and Compassionate for the Chronically Critically Ill." At that point the editors gave up and decided this issue's final title would be determined only after the papers were submitted and reviewed. The struggle to name the issue reflects the entanglements that set law, medicine, and ethics in a spin over the relations between costs of care, on the one hand, and on the other, rationality as an applicable adjudicator of treatment decisions involving patients who are not expected to survive a current illness, or if they do survive, will be unable to return to a normal health status.
Health Care Accessibility for Chronic Illness Management and End-of-Life Care: A View from Rural America
Kathryn E. Artnak, Richard M. McGraw, and Vayden F. Stanley - [PDF]

Introduction: The Institute of Medicine (IOM) reporting on the quality of health care in America recommends six aims for achieving the health care system we could have. Together with the Institute for Healthcare Improvement (IHI) Triple Aim initiative, a framework has emerged to challenge providers, educators, and policymakers to remake the health care system according to specific objectives: to provide care that is safe, effective, patient-centered, timely, efficient, and equitable to more people at a price we can afford. Complicating this mission of better prevention and better care at a lower cost is a daunting demographic: January of 2011 marked the month and year that the first of the baby boomers turned 65. The U.S. Census Bureau in May 2010 projected the number of Americans of this age and over to reach 88 million by 2050, more than double the current figure of 40.2 million. Parekh and Barton forecast in stark detail what it will be like to address these burgeoning numbers of older Americans with comorbidities, including the fact that over 20% of the population currently experiences at least two chronic medical conditions. Persons with chronic illnesses require more health care services, are costlier to treat, and are a significant factor in the rise of health care spending. And the likelihood of incurring an additional chronic illness increases with age. Contrary to what many believe, most Americans do not die from cancer; they die from complications related to chronic illness (see Figure 1). And adults are not the only ones affected; children suffer from chronic illness, too. In fact, chronic illness is the leading cause of death in children.
Just Caring: Health Care Rationing, Terminal Illness, and the Medically Least Well Off
Leonard M. Fleck - [PDF]

What does it mean to be a "just" and "caring" society in meeting the health care needs of the terminally ill when we have only limited resources to meet virtually unlimited health care needs? This is the question that will be the focus of this essay. Another way of asking our question would be the following: Relative to all the other health care needs in our society, especially the need for lifesaving or life-prolonging health care, how high a priority ought the health care needs of persons who are terminally ill have? Should any of the health care needs of the terminally ill be assigned very low priority? Or should all their health care needs be assigned the highest priority? If we reflect a bit, we will find ourselves greatly internally conflicted. On the one hand, the "caring" side of our moral self might see terminally ill individuals as being among the "medically least well off," and therefore, deserving virtually any medical resources that will yield any degree of good for them. On the other hand, the "just" side of our moral self might see medical resources squandered on individuals who can benefit only marginally while other serious health needs in our society go unmet for lack of resources. How should these conflicting moral commitments be balanced?
Futility, Autonomy, and Cost in End-of-Life Care
Mary Ann Baily - [PDF]

Introduction: In 1989, Helga Wanglie, 86 years old, broke her hip. This began a medical downhill course that a year later caused her health care providers to conclude that she would not benefit from continued medical treatment. It would be futile, and therefore, should not be provided. Her husband (the surrogate decision maker) disagreed, and the conflict eventually led to a lawsuit. The Wanglie case touched off an extended debate in the medical and bioethical literature about medical futility: what it means and how useful the concept is in making ethical decisions about starting or stopping treatment. Futility does not arise only in the end-of-life context: for example, taking an antibiotic for a viral illness is futile. However, the most volatile futility controversies tend to arise in the context of life-sustaining treatments and end-of-life scenarios. In this paper, I will focus on futility in this context, since my intention is to use the futility debate as a window into the broader issue of the role of cost in decisions about treatment near the end of life. The paper does not try to survey all the issues addressed in the futility literature, but focuses on one aspect of decision making that has not received the attention it deserves: the difference between refusing medical treatment and demanding it.
Making the Case for Talking to Patients about the Costs of End-of-Life Care
Greer Donley and Marion Danis - [PDF]

The cost of health care at the end of life accounts for a high proportion of total health care costs in the United States. The percentage of Medicare payments attributable to patients in their last year of life was 28.3% in 1978 and has remained substantially the same at 25.1% in 2006. This indicates how little progress has been made in containing these costs, though doing so will be important to promote a financially sustainable health care system. These expenditures also highlight the prospect that efforts to reduce health care costs overall are likely to disproportionately affect the care patients receive at the end of life.
Costs and End-of-Life Care in the NICU: Lessons for the MICU?
John D. Lantos and William L. Meadow - [PDF]

Providing care for a baby born at 24 weeks of gestation in a neonatal intensive care unit (NICU) is one of the most expensive medical treatments in the United States today. The cost can easily run over $300,000 for one baby. Furthermore, many extremely premature babies who survive are left with chronic diseases or disabilities that require further medical expenses and other specialized services throughout childhood or throughout life. When all these expenditures are totaled up, it can seem that neonatal intensive care is just not worth it. Concerns about the cost-effectiveness of NICUs have led to persistent critical scrutiny of these specialized units by physicians, economists, and epidemiologists. These analysts have examined NICUs and the patients in them in order to determine whether there are subpopulations of babies for whom neonatal intensive care is so demonstrably ineffective or so costly that it should not be provided. Such examinations have been carried out in many different countries, at many times over the last 30 years, and have analyzed outcomes for babies by gestational age, birthweight, and illness severity.
End-of-Life Decision Making across Cultures
Robert H. Blank - [PDF]

As is evident from the other articles in this special issue, end-of-life treatment has engendered a vigorous dialogue in the United States over the past few decades because decision making at the end of life raises broad and difficult ethical issues that touch on health professionals, patients, and their families. This concern is exacerbated by the high cost related to the end of life in the U.S. Moreover, in light of demographic patterns, progressively scarce health care resources, and an expanding array of life-saving technologies, decisions at the end of life are becoming problematic matters of public and, thus, scholarly concern in most countries. Issues at the end of life are central not only to bioethics but also raise important ancillary policy dimensions.
The Value of Life at the End of Life: A Critical Assessment of Hope and Other Factors
Paul T. Menzel - [PDF]

Introduction: "The thing about life is that one day you'll be dead." Indeed. But even total and honest acceptance of this brute fact about our relationship to death does not diminish the value we see in short remaining life at the end of life. Few just "give in" and no more fight for life because death is seen as an inherent part of life. They still invest small amounts of additional life with huge value. How high may that value plausibly be? What is the value of a relatively short extension of life when death is inevitably near? These focal questions should not be confused with questions about life's age-related value. The question is not, for example, what value a year of life in more senior years has compared to a year of life in younger years. The question of the value of life at the end of life can arise at any age -- for dying children, for example, as well as for dying octogenarians. Nor is the question for this paper the aggregate value question of whether an increase in a population's longevity is worth the various costs and disruptions it entails (pensions, health care, social structures and relationships, etc.). It is instead a question about individual life: how much value does the extension of someone's life by a likely two months, for example, have, when in any case she will not live longer than four?
In the Business of Dying: Questioning the Commercialization of Hospice
Joshua E. Perry and Robert C. Stone - [PDF]

Introduction: The hospice movement in the United States is approximately 40 years old. During these past four decades, the concept of holistic, multidisciplinary care for patients (and their families) who are suffering from a terminal illness has evolved from a modest, grassroots constellation of primarily volunteer-run and community-governed endeavors to a multimillion dollar industry where the surviving nonprofits compete with for-profit providers, often publicly traded, managed by M.B.A.-trained executives, and governed by corporate boards. The relatively recent emergence of for-profit hospice reflects an increasing commercialization of health care in the United States, the potentially adverse impact of which has been well documented. Here we refer to the general threats against medicine's ethical foundations that are made by health care organizations attempting to marry the "fundamental objective" of commerce, i.e., "achieving an excess of revenue over costs" so as to ensure profits for owners and investors, with the delivery of quality care to vulnerable consumers who are often compromised in their ability to make decisions. In the case of hospice, of course, the "customer" suffers from a terminal condition, which intensifies ethical concerns regarding the priority of the patient's needs (ahead of profit-taking), the importance of dealing with patients "honestly, competently, and compassionately," and the avoidance of any conflicts of interest "that could undermine public trust in the altruism of medicine."
Independent Articles
Fetal Pain, Abortion, Viability, and the Constitution
I. Glenn Cohen and Sadath Sayeed - [PDF]

On April 13, 2010, Nebraska enacted a new state ban on abortion in the Pain-Capable Unborn Child Protection Act that has caught the attention of many on both sides of the abortion debate, and has inspired other states to attempt similar measures. The statute requires the referring or abortion-providing physician to make a "determination of the probable postfertilization age of the unborn child" (defined as, "the age of the unborn child as calculated from the fertilization of the human ovum") and makes it illegal to induce or attempt to perform or induce an abortion upon a woman when the "probable postfertilization age" of the fetus is "twenty or more weeks" unless the doctor determines in "reasonable medical judgment (1) she has a condition which so complicates her medical condition as to necessitate the abortion of her pregnancy to avert her death or to avert serious risk of substantial and irreversible physical impairment of a major bodily function or (2) it is necessary to preserve the life of an unborn child." It also offers a civil action to the father of the unborn child, its grandparents, or the woman for "knowing or reckless violation of the act for actual damages," as well as providing for injunctive relief.
A Living Wage for Research Subjects
Trisha B. Phillips - [PDF]

Introduction: Offering cash payments to research subjects is a common recruiting method, but this practice continues to be controversial because of its potential to compromise the protection of human subjects. Some critics question whether researchers should be allowed to offer money at all, citing concerns about commodification of the research subject, invalidation of study results, and increased risks to subjects. Other critics are comfortable with the idea of monetary payments but question how much researchers can pay their subjects, citing concerns about undue inducement, crowding out, and monetary exploitation. Focusing only on the amount researchers can pay their subjects, this paper argues that the federal regulations and guidelines should implement a standard payment formula. It argues for a wage payment model, and critically examines three candidates for a base wage: the nonfarm production wage, the FLSA minimum wage, and a living wage. After showing that the nonfarm production wage is too high to satisfy ethical criteria, and the minimum wage is too low, this paper concludes that the wage payment model with a base wage equivalent to a living wage is the best candidate for a standard payment formula in human subjects research.
Multi-Professional Recommendations for Access and Utilization of Critical Care Services: Towards Consistency in Practice and Ethical Decision-Making Processes
Laura Hawryluck, Redouane Bouali, and Nathalie Danjoux Meth - [PDF]

Introduction: The ethics sections of Critical Care Societies have issued position statements and proposed a variety of position papers and policies describing the appropriate use of critical care services. These policies describe the goals of critical care provision -- to support a patient through an acute, potentially reversible, life-threatening illness -- and provide broad guidance on physiological and hemodynamic criteria that require the specialized care of an ICU environment. In recent years, many critical care professionals have, however, reported providing care they felt was inappropriate or futile even though most felt they should not have done so. Futile care encompasses treatments that will not work or treatments that have no chance of providing any benefit. ICU teams define care as inappropriate when it fails to restore a person to an awareness of self, and an ability to interact with their environment particularly when a lot of critical care resources are required. When patients experience significant amounts of pain and suffering, such care seems even more inappropriate. Existing policies fall short of meeting the pressing needs of front-line clinicians as there is no consistent way to guide critical care teams in balancing the rights of an individual to have his or her wishes and beliefs respected regarding the use of life support and the rights of others to access this limited resources in increasingly multicultural societies. Additionally, the professional values of ICU teams, epitomized in the fundamental principle of "first do no harm," are increasingly challenged when the material risks and side effects of life support outweigh potential benefits -- such as when patients insist on resuscitative measures when life support is not expected to help and will only add (often exponentially) to their suffering, when such wishes for support continue in the face of rapidly diminishing chances of survival, or when life support will only prolong a terminally ill patient's death. It remains unclear who -- patients, professionals, or society -- should have definitive say in resolving such dilemmas. Indeed questions of who holds the "trump card" are not necessarily productive, and a better approach would be a collaborative process in which agreement is forged between professionals, society, and potential future patients in how to appropriately use critical care services to best help patients with life-threatening illnesses.
Testing Public Health Ethics: Why the CDC's HIV Screening Recommendations May Violate the Least Infringement Principle
Matthew W. Pierce, Suzanne Maman, Allison K. Groves, Elizabeth J. King, and Sarah C. Wyckoff - [PDF]

Introduction: The least infringement principle has been widely endorsed by public health scholars. According to this principle, public health policies may infringe upon "general moral considerations" in order to achieve a public health goal, but if two policies provide the same public health benefit, then policymakers should choose the one that infringes least upon "general moral considerations." General moral considerations can encompass a wide variety of goals, including fair distribution of burdens and benefits, protection of privacy and confidentiality, and respect for autonomy. In this article, we argue that the Center for Disease Control and Prevention's (CDC) 2006 HIV screening recommendations ("Recommendations") may violate the least infringement principle. This is a concern because, although not legally binding, the Recommendations appear to have already influenced state laws and will likely continue to do so as legislative proposals continue to be passed.6 At a minimum, therefore, the Recommendations have important implications for HIV screening within the United States.
Reining In the Pharmacological Enhancement Train: We Should Remain Vigilant about Regulatory Standards for Prescribing Controlled Substances
Katherine Drabiak-Syed - [PDF]

Introduction: In the March 2010 edition of Mayo Clinic Proceedings, Drs. Rose and Curry declared that resident physicians have an ethical duty to reduce error during periods of fatigue. Problematically, however, they argued this means ingesting a stimulant for performance enhancement and sleep avoidance (hereinafter "PESA") during a shift when a resident physician is experiencing fatigue as the more ethical choice than forgoing ingesting a stimulant. Rather than accepting enhancement as an unstoppable technological imperative, this article will examine the underlying motivations for enhancement embedded in our culture and the corresponding legal framework relating to stimulant drugs. Although our society seems to be engaged in a pharmacological arms race of efficiency, competition, and self "betterment," the FDA has not approved stimulant drugs such as modafinil for PESA. As a result, the off-label use of modafinil for PESA means these individuals are part of a large-scale experiment that poses serious immediate and long-term side effects to the individual user as well as society. More importantly, a physician's practice of prescribing a controlled substance such as modafinil for PESA runs contrary to a physician's ethical duty to the patient and the standard of practice set forth in legal requirements governing the prescription of controlled substances. Exploiting and ignoring these legal standards of practice will put the patient, the physician, and society at risk for dangerous health and social consequences.
Columns
Currents in Contemporary Bioethics: Constitutional Right to Informational Health Privacy in Critical Condition
Mark A. Rothstein - [PDF]

Legal protections for health privacy depend on the person whose information is disclosed, the type of information disclosed, the individual or entity disclosing the information, the method of disclosure, the consequences of disclosure, the jurisdiction in which the disclosure takes place, and other factors. With so many variables, it is not surprising that protections for health privacy are inconsistent and inadequate. For more than three decades the federal courts seemed to recognize that governmental disclosures of an individual's sensitive health information violated the Constitution. Two recent cases, however, have cast great doubt on the vitality of this asserted constitutional right.
Teaching Health Law: Personal Reflections on Teaching Health Law in a School of Public Health
Peter D. Jacobson - [PDF]

Introduction: For the past 20 years, I have been teaching various law courses, mostly to public health students. At the RAND Graduate School, I taught two courses to Ph.D. candidates: one on law and social science, and then a course on law and epidemiology (co-listed with the UCLA School of Public Health). Each year since 1996 at the University of Michigan School of Public Health (UMSPH), I have been teaching health law to our Master of Health Services Administration (MHSA) candidates, and public health law to Master of Public Health (MPH) candidates. I also teach a seminar on health care regulations. In 2004, I taught health law at the Georgetown University Law Center as a visiting scholar. The non-law student audience presents a different set of challenges than does teaching law students, even though my UMSPH classes usually include at least one dual law/public health degree candidate (and an occasional law student). Teaching a multidisciplinary cohort with little prior exposure to law is an exciting challenge that offers many rewards. What follows are some observations about how to approach teaching health law to non-law students.
Recent Developments in Health Law: Essential Medicines: Why International Price Discrimination May Increasingly Be the Wrong Solution to a Global Drug Problem
Jonathan J. Darrow - [PDF]

The World Health Organization's (WHO) updated List of Essential Medicines, scheduled to be published in March 2011, is expected to include more than 340 pharmaceuticals and related products. The list, first compiled in 1977 and revised every two years, includes medicines based on criteria of "public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness." Although almost all of the drugs on the list are now off-patent (with important exceptions for drugs related to AIDS and treatment-resistant tuberculosis), some observers continue to advocate price discrimination as a cornerstone of the solution to the global drug problem. The theoretical appeal of international pharmaceutical price discrimination derives from its ability to place essential medicines within reach of patients in low-income countries, while simultaneously allowing industry to recoup its significant research and development costs by selling the same drugs at much higher prices in high-income countries. Because of its perceived advantages, price discrimination has been embraced by the World Health Organization, national governments, scholars, human rights organizations, and even the pharmaceutical industry itself. Although price discrimination has been partially successful in the past, it has never been an optimal solution to the global drug problem for the reasons discussed below. More importantly, an evolving global environment has rendered the practice increasingly ineffective, unfair, and threatening to future drug research. Fortunately, Advance Market Commitments (AMCs) and other approaches have recently shown great promise as effective solutions to the global drug problem, and may be less susceptible to the shortcomings of discriminatory pricing.