CCBIO on Ethics (2014)
Health Priorities Should Be Open, Just and Smart
Medical innovations provide health benefits. They also tend to incur increased costs to the health care system, simply because a novel benefit can create a demand from which the supply side can profit. This is a basic fact of capitalist societies.
While Norwegian politicians, health personnel and citizens might disagree as to whether public health expenditures are too high or indeed too low, it remains a fact that they are increasing. In 2013, the amount of 288 billion NOK (37 billion euros) was spent on public health in Norway, representing an average expenditure of 56 700 NOK/citizen. So far, Norway’s wealthy oil economy has had little difficulty absorbing these costs. 2014, however, was the year when Norway experienced an awakening from its oil-lubricated financial slumber. The oil price dropped dramatically, with immediate consequences for employment. As a fortunate coincidence, the Norwegian governmental expert group on public health prioritization submitted its final report “Open and just - priorities in the Norwegian healthcare services”. Its main conclusion is that health prioritization needs to be systematic, transparent, based on general criteria, effective and anchored in the goal of “as many good life-years for everybody, fairly distributed”.
Exactly what this will imply for expensive cancer treatments remains to be seen. Recent cancer drug developments have created health benefits, hope, perhaps hype and definitely public controversy. Some of the ethics debates that emerged, appeared more as tragedies than dilemmas- sick individuals getting hopes from therapeutic options that simply cannot be afforded.
More scientific knowledge does not by itself alleviate the ethical tragedies. Indeed, research is in a sense their principal creator. When we call for smarter prioritization, the challenge is not mainly that public decision-makers should become better versed in science. Rather, from the CCBIO perspective, cancer research itself needs to become smarter, develop smarter knowledge that can resolve old problems and produce fewer new ones.
Research on cancer biomarkers bears this promise of smarter science. Part of the tragedy when the individual patient cannot receive a promising treatment because it is not cost-effective on a population level, is the lack of applicable knowledge on the sub-population level. Biomarkers that produce finer stratifications may reduce the tension between clinical wisdom and the need for general decision criteria. At least some biomarkers may have this effect.
The social role and function of knowledge
This call for smarter science in the name of ethics may seem innocent. It is not. It marks what since the 1990s has been called “the new social contract of science” – a call for researchers to temper their passion for knowledge and not rush ahead, driven by their curiosity alone. Rather, the researchers are asked to consider the social role and function of his knowledge before it is produced. It is a call for anticipatory ethics of science; a type of ethics that hardly exists and is profoundly inexact. Recently, European research policies have developed the concept of “Responsible Research and Innovation” (RRI; similar to what in the US is called anticipatory governance of science). In Horizon 2020, RRI was made a cross-cutting principle by the European Parliament. One can witness a new request from society onto science: the request not only to produce knowledge but smart knowledge that can promote socially robust decision-making. Some would say this is an impossible request; at CCBIO, claims of impossibility tend to whet our appetite.
Vision and Research Areas
CCBIO aims to discover, validate and translate functional cancer biomarkers to improve biological understanding, early diagnosis of aggressive phenotypes and treatment of cancer.
CCBIO has a focus on tumor-microenvironment interactions in primary and metastatic lesions and how they can define aggressive tumor features and predict cancer progression patterns. The center is studying how cross-talk between tumor cells and components in the tumor microenvironment reflect cancer complexity and heterogeneity and determine cancer prognosis, beyond what is given by description of genetic alterations in tumor cells.
By three overlapping research areas, CCBIO will re-focus its cancer research into the following main programs:
1. Mechanisms of Tumor-Microenvironment Interactions (Preclinical Studies)
2. Exploration and Validation of Cancer Biomarkers (Biomarker Validation)
3. Clinical Applications and Trial Studies (Clinical Studies)
Biomedical project areas have been supplemented with integrated ethics and economics projects, focused on how to prioritize and fund expensive cancer treatment in the era of expanding and costly personalized medicine. New collaboration partners, both national and international, have been included to support our efforts.