【草莓酱拌饭组】ECONOMICS DEBATE1 by Gary

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注：紫色——GRE词

橙色——有关主题结构

红色——生词

Health care

This house believes that the widespread use of comparative effectiveness reviews and cost/benefit analyses will stifle medical innovation and lead to an unacceptable rationing of health care.

The moderator's opening remarks

Oct 6th 2009 | Mr Vijay V. Vaitheeswaran

As the rich world grows older and sicker and the poor world gets wealthier and fatter, the cost of health care is soaring. Governments and insurers(insurance) the world over are struggling to cope with runaway health inflation(形容价格增加可用). Adding to the demographic shift in OECD countries and the wealth effect in the emerging giants is the unprecedented wave of technological innovation in new pills, procedures and devices（设施） made possible by the ongoing convergence（同化） of biology and engineering.

The potential health and welfare benefits of this revolution(innovation) are breathtaking（吃惊的）, every bit as much as the wave of innovation that earlier produced vaccines, for example, which are among the most powerful of all health interventions. But the coming grand convergence could, some argue, instead turn into a tale of need versus(vs) greed, a conflict between the haves and have nots.

Even if such a battle royal is not on the cards, the pace of medical innovation and the seemingly insatiable growth in demand for health care certainly raise the question of how to pay for future medical marvels. （提出论题）Some argue that commonsense tests of economics, ranging from cost-benefit analysis to comparative effectiveness reviews, are essential to weed out the worthy from the wasteful(去除糟粕). But others argue that such tools are crude and anti-innovation at best, and, if wielded by stingy governments, implements of cruel health-care rationing（定量供给） (or "death panels", as Sarah Palin, the former Alaskan governor, famously called this) at worst.

One of the most prominent voices making the latter case of late has been Newt Gingrich, the former Speaker of America's House of Representatives. In his aggressive opening defence of the motion for our debate, he makes a clear link between comparative effectiveness reviews (CERs) and patient harm: when such tools are "combined with the pressure to control costs and the power to decide who gets what," he insists, "innovation will suffer and patients will suffer."

Mr Gingrich's strident arguments appear to flow from a political philosophy, much more commonly expressed in America than in Europe, that emphasises individual rights and choices over collective action or the optimal（最优的）societal outcome. On his view, a rational （可推理的，理性的）health-care future will emphasise personalised therapies tailored to the genetic needs of the individual, not the number-crunched（咀嚼发出的声音） and coldly utilitarian calculus offered by CERs. The sharp end of his argument is summed up by this simple question: "Do you want the government to decide?"

Britain's National Institute for Health and Clinical Excellence (NICE) is a government body that has pioneered the use of CERs and other related policies. Sir Michael Rawlins, its chairman, offers a full-throated defence of that approach as his opening salvo in opposition to the motion. He makes it plain early on that his faith in comparative effectiveness tools flows from a respect for the social compact by posing this revealing rhetorical（修辞的） question: "On what basis should nations use their resources to treat ill-health in a manner that is fair to all?（论证时可用）" This suggests his thinking is more in line with European sensibilities. Defenders of America's individualistic and market-oriented health system often say that it is better and more innovative than its rivals, but few dare to claim that it is "fair to all".

G(Gingrich)是美国式的思维

M(Michael)是欧式思维

Sir Michael insists that the use of CERs has grown into a "sophisticated scientific discipline" that seeks to answer two critical questions: does a new technology offer benefits when compared with existing options, and if so by how much? He points to various case studies, including the increased use of thromolytic technology to treat heart attacks and diminished use of SSRI ('selective serotonin reuptake inhibitors') anti-depressants to treat children, that prove the value of CERs. Taking all the evidence into account, he thunders: "It is inconceivable that any rational person would either object to, or want to stand in the way of, comparative effectiveness reviews."

The topic of our debate is a timely and important one. Our debaters are genuine heavyweights and, as their opening arguments make plain, are spoiling for a fight. The first shots have been fired. Now is the time for you, gentle reader, to weigh in with your vote.

The proposer's opening remarks

Oct 6th 2009 | Newt Gingrich

In a recent Wall Street Journal column, I told the story of a three-year-old boy who was diagnosed with a rare, aggressive form of bladder cancer. His parents were told that his chance of survival was 50%.

Their options included ①radical surgery to remove his bladder（胆囊）, prostate（前列腺）, and portions of his rectum（直肠）. The side effects included impotence, a colostomy bag, and having to urinate through a bag in his abdomen. ②Radiation was also an option, but because he was so young, his pelvic bones and hips（臀部） would not grow properly, and his bladder would remain the size of a three-year-old's for the rest of his life.（2种传统疗法及其影响）

His parents were also told of an "unproven" option: ③proton beam therapy（质子射线疗法）. Proton beams would target the radiation dose to limit the radiation scatter, which would avoid extensive damage to his body. The targeted beam would also likely be more effective at killing the cancer cells. While the clinical research was insufficient, the physicians' recommendations were unanimous. The boy underwent （经历）the treatment. He responded beautifully and is now cancer free, living a normal, healthy life.（先进疗法）

Innovation and technology saved his life. Government-imposed comparative effectiveness research did not.（通过举一个三岁小孩得了一种囊状癌症，传统的治疗方案和先进的但缺乏临床验证的治疗方案影响的比较，最后选择了后者。得出结论，是改革和技术而不是政府强制性的比较效益救了孩子的命。）

In fact, because there is little science on using proton beam therapy for pediatric cancers, a strict adherence to comparative effectiveness research would probably have led to the boy's death or certainly his mutilation（损害）. In most nationalized health systems, his parents would likely have been denied（deny） the power to choose this treatment because government-imposed comparative effectiveness research would have deemed it unproven, investigational, or experimental.

G结合例子提出CEC可能对质子射线疗法的看法，以说明其思维的局限性。

As ①Thomas Kuhn so powerfully explained in his masterwork The Structure of Scientific Revolutions, new science is always unproven at first. But today's breakthroughs regularly become tomorrow's routine treatments. Just look at ②Lance Armstrong's triple drug combination for metastatic testicular cancer. Many similar innovations were discovered not through population-based research, such as comparative effectiveness, but through personalized application with specific individuals.

That is not to say that population-based research has no role. I have long advocated that knowing whether a treatment, pharmaceutical, or technology actually works will lead to better health and better quality because individuals could get the right treatment at the right time and not pay the opportunity costs associated with pursuing ineffective treatments. This kind of knowledge can give patients and their families important information to make more informed, individual, and independent decisions with their doctors.

As my friend in this debate, Sir Michael Rawlins, recently said of all the various options to treat prostate cancer, "We're not sure how good any of these treatments are." Sir Rawlins is right that for prostate cancer, and indeed for most treatments, we cannot predict what will work and what will not for specific individuals. However, knowing what works across a large population is not the same as knowing what is best for an individual.

For example, let's say（比如说，表让步，用作插入语） comparative effectiveness research is used to determine the efficacy of new drug treatments. Population research reveals that drug A works 70 percent of time and drug B works 60 percent of time. A strict adherence（附属，应该是自然而然推出之意） to comparative effectiveness would rule drug A the winner. But what if the 30 percent of people who did not respond to drug A did respond to drug B? Or what about the even smaller groups that may have responded best to drug X, Y, or Z? Population-based research is ill-equipped to answer these kinds of questions.

Comparative effectiveness often leads to an even more dangerous outcome. When effectiveness is combined with the pressure to control costs and the power to decide who gets what, innovation will suffer and patients will suffer. That is because many see comparative effectiveness as a way for government to allocate scarce medical resources. Sir Rawlins implied as much when he wrote last year: "Countries do not have infinite sums of money to spend on health… The debate is not about whether - but how - healthcare budgets can be most fairly shared out among a country's citizenry（同citizen）."

Governments, like the United Kingdom, use comparative effectiveness to decide what treatments its citizens can get, from diagnostics, laboratories, and imaging to new innovative drugs and therapies. Go back to the example of drug research. What happens when a drug is more effective than another but costs three times as much? To make this decision, government must weigh the costs it will bear with your quality of life. Do you want government to decide that the more expensive drug isn't worth the cost for you to have less pain and suffering?

Government placing a numeric value on an individual's life, such as the quality adjusted life year formula, or placing a value on an individual's quality of life is anathema（同curse） to the very foundation of the United States. Our Constitution values life as an unalienable(无法转让的) right endowed by our Creator. How can you place a numeric value on an unalienable right?

In addition to the restrictions（限制） this imposes on individuals accessing care, this has profound implications for creating or discovering the next breakthrough. What good is a new breakthrough if government decides you can't have it? Take the earlier example of proton beam therapy. There are questions whether it is the most effective way to treat prostate cancer, its most common use. If these questions had led to a wide restriction on using it to treat prostate cancer, would doctors have ever had the opportunity to try it as a treatment for pediatric cancer? New science and innovation would be dramatically（显著地） reduced if innovators and entrepreneurs have little hope of their products reaching patients.

21st century science and innovation is moving toward personalized, individual-centered medicine, like genetics, and away from population-based research, like comparative effectiveness. We need to embrace and encourage ways to understand how a specific individual will respond to a specific treatment, not try to determine the lowest common denominator for everyone. This kind of research will give rise to a rational—not rationed—healthcare system.