Justice

The three examples from the field of child psychopharmacotherapy have shown that, in general, the treatment of children today cannot be based on the same level of safety data as the treatment of adults. Consequently, a highly vulnerable subgroup of our population that should be particularly well protected ironically suffers from an unacceptable lack of data concerning age specific dosages and effects as well as side effects, even for the most commonly used drugs in child and adolescent psychopharmacotherapy. Children can therefore be described as therapeutic orphans. The health and economy discussion about justice of distribution of healthcare interventions is increasingly dominated by allocation issues. Will it be possible for everybody in a given society to be granted the same access to new intervention techniques? Even now there are dramatic differences with respect to the use of new pharmacological agents between the United States, some countries of Europe and, especially, countries in the Third World. Will new interventions only be accessible to rich, well insured citizens of wealthy countries? Do the patients with the most severe symptomatology get the best treatment? Even our current pharmacoepidemiological comparisons between the United States and Europe show wide differences. In Germany, for example, fixed budgets in outpatient care lead to a very conservative prescription pattern concerning psychopharmacological drugs in children and adolescents. The first generation neuroleptics and the old tricyclic antidepressants still dominate the German market, whereas in the United States more than 90% of the prescriptions to children and adolescents are for new and much more expensive drugs. As a new drug is not always the better or even safer option, there is no simple answer to the question whether a restrictive system with fixed budgets that stimulates the prescription of old and cheap generic drugs or a system that encourages innovations is more conducive to general mental health. In Germany there is a risk that patients may not profit from the advances of interventions, but at the same time German patients are less at risk from aggressive marketing strategies for novel interventions. The National Health Service in Britain, for example, has not adopted slow release stimulants for free-of-charge treatment because there is no proof of superiority with respect to the therapeutic effects of the slow-release medication over repeated administration of a regular pill. Still, is a more convenient regime of drug intake and the reduction of stigma at school just a cosmetic effect, or should such aspects be taken into consideration? At present in the UK, well-off parents can always buy long-acting stimulants for their children, whereas poorer families have to rely on the National Health Service. In the future, pharmacoeconomic studies that take into account quality-of-life measures and calculate the benefit of novel interventions in the brain in terms of quality-adjusted life years will be very important in the process of making available alternative treatments or new interventions in the brain.

1.5.5 A Cultural Perspective

Disease concepts may vary between cultures. The perception of whether a small boy is hyperactive or not differs considerably between e.g. China, Mediterranean countries like Greece, Italy or Spain, and countries like the United States, Germany or the Netherlands. Many cultural differences are reflected even in the diagnostic systems used in the United States and Europe. This variation of diagnostic systems leads to an enormous difference in drug consumption between European countries and the United States (the lack of access to psychosocial interventions in the U.S. may be an exacerbating factor). Many of our study results are based on definitions of psychiatric diseases in that particular society.

The concept of the importance of a child's or an adolescent's individual will might appear very strange in the Japanese culture, for example, where the family usually decides the measures to be taken for a sick family member, even an adult. So, many ethical questions concerning novel interventions in the brain must be answered in different ways with respect to different cultural backgrounds. If we want to rely on the public control of forced interventions in the best interest of the patient, we have to make sure that the culture that defines this best interest subscribes to universal humanitarian principles and is ready to accept that every human being has fundamental rights. So if, according to some philosophical definitions, a small child is not yet a person, and if this human being with all the potential of personhood undergoes a preventive intervention in his brain, will this affect his future personality? Would this constitute an attack on his rights as a human being? These days there is widespread enthusiasm for the future possibilities of neuroprotection, once we can define molecular targets. But who can consent to neu-roprotective interventions in the most needy, for example in children neglected and traumatised in infancy by their natural parents?

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