The divergent languages of business and medicine

My business ethics class recently discussed the case of Cipla Pharmaceuticals, an Indian generic drug manufacturer drawing the ire of big pharma by blithely ignoring international patents or employing workarounds to manufacture low-cost generics in direct violation of the patents. Cipla’s founder, Dr. Yusuf Hamied, stressed that Cipla’s goal wasn’t to steal from the bottom line of the likes of Merck and Eli Lilly, but rather to serve its mission of helping the world’s poor gain access to life-saving medications that they could otherwise not afford.

The class discussion was vigorous. Students hailing from careers in pharma vehemently stated their opposition to Cipla’s cause, invoking the necessity for pharmaceutical companies to amortize their costs through sales. Though the incremental costs per pill of actual manufacturing were negligible, the high initial investments in research trials and production required a modicum of intellectual property protection. By capitalizing on the more liberal Indian patent laws, Cipla was undermining their pricing model and directly stealing customer segments.

Others disagreed. After all, the world’s poorest of the poor represented a market that would have been priced out of its products anyway. The case study offered some numbers on the lowest margin that these companies would be able to offer without selling at a loss. The comparison was, roughly, $12,000 versus Cipla’s $300. For the average consumer in the developing world, the treatment was completely out of reach.

At the midpoint of discussion, a classmate from the Middle East, who had been holding back furious tears through most of the discussion, raised a trembling hand and broke his silence. He told us of how his father, when he contracted diabetes, would not have survived if not for the availability of exactly such generic drugs.

He said, “This entire discussion disgusts me.” The sentiment resonated, and most everyone looked down at his or her desk, suddenly chastened.

As a dual degree student in medicine and business, I’m always fascinated by the differences in vocabulary at the two different schools. Back in medical school, we talk about global health, social justice, structural violence, institutional discrimination — the keywords vary but the takeaway is often just this: Health care is a basic human right, and one doesn’t ever turn away a suffering patient, ever.

In fact, the likes of Paul Farmer and Partners in Health take this a step further and elaborate on a physician’s obligations to extend into examining and advocating for change to the social determinants of health, the conditions in which people are born, grow and age, shaped as they are by the distribution of capital and resources at both the global and local level.

As I sat in my front-row seat, I remembered working late nights in the emergency room, convincing the uninsured to accept treatment without fear of going bankrupt. I remembered slipping a $5 bill to a patient in primary care clinic who was non-compliant with her medication regimen because she could not even afford this, the cost of the generic. I remembered traveling to small village-based clinics in India with medical teams, and holding hands with impoverished farmers, feeling ashamed by the disparities in personal wealth and opportunities between us, and ardently wishing for a better world.

At the business school, we use words like incentives, value proposition and return on equity. The liberals in the room had to couch their arguments in these terms. It would have been indelicate to talk about human rights and moral obligations. Instead, perhaps individual governments could leverage their bargaining power and purchase medications for their citizens in bulk. Perhaps governments could directly subsidize medications for their populace.

One of my friends raised his hand and began his comment with “I really do feel a lot of pity for these folks, but I believe strongly that protecting patents is the only way to incentivize …”

I thought about that for a while. The word pity. Synonyms for pity abounded in the discussion, as everyone strove to couch their comments with such a proviso: understand, regret, sorrow, empathy. What do these mean?

While dying of prostate cancer, the late New York Times book critic Anatole Broyard wrote in his memoir, Intoxicated by My Illness, that he expected his doctor to do more than be a “close reader of illness.”

“I see no reason or need for my doctor to love me — nor would I expect him to suffer with me. […] I just wish he would brood on my situation for perhaps five minutes.”

In her Los Angeles Times review of Leslie Jamison’s The Empathy Exams, columnist Suzanne Koven notes that the word “empathy” itself is new, absent even in the 1971 edition of the Oxford English Dictionary.

This represents a seismic cultural shift. Where previously a physician may have been expected to possess intelligence and integrity in good measure, now the third, empathy, has risen to equal if not greater importance.

Empathy, “to suffer with,” is a tall order. When you put yourself in another person’s shoes and consider the weight of their world, no matter if you are a physician, an insurance agent, a lawyer, a business person, there are no caveats. True empathy doesn’t allow for “I feel sorry but …” When you imagine yourself inhabiting your patient’s life, with the all the daily humiliations of poverty, hunger, sanitation, and unfair infrastructure pressing down on you, it becomes impossible to shake that off, and speak only dispassionately on the subject of life and health.

And yet, all of this comes to nothing if those advocating for patients are unable to frame their arguments within the economic lens. The reality of health care is that it operates in the free market, on limited budgets, and paid for by private agencies.

The language of medicine and the language of business don’t simply diverge on technical points. It’s more than a financier’s inability to interpret lab data, or a physician’s impotence at discounting cash flows. It’s in the very definitions of access and rights and economics and morality.

It’s imperative that participants talk with citizens of both spheres, knowing that the divergence lies even deeper, in fundamental views of the world and in considering how humans ought to care for each other.

Samyukta Mullangi is a medical student who writes at her self-titled site, Samyukta Mullangi.

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