Clinical decision making is the process by which we determine

The disease onchocerciasis, known as river blindness, is caused by parasitic worms that live in the small black flies that breed in and about fast-moving rivers in developing countries in the Middle East, Africa, and Latin America. When a person is bitten by a fly, the larvae of the worm can enter the person’s body. The worms can grow to almost two feet long and can cause grotesque growths in an infected person. The real trouble comes, however, when the worms begin to reproduce and release millions of microscopic baby worms into a person’s systems. The itching is so intense that some infected people have committed suicide. As time passes, the larvae continue to cause severe problems, including blindness. In 1978, the World Health Organization estimated that more than 300,000 people were blind because of the disease, and another 18 million were infected. In addition, in 1978, the disease had no safe cure. Only two drugs could kill the parasite, but both had serious, even fatal side effects. At the time, the only measure being taken to combat river blindness was the spraying of infected rivers with insecticides in the hope of killing the flies. However, even this was not effective since the flies had built up immunity to the chemicals. Because it often takes over $200 million in research and 12 years to bring an average drug to market, a pharmaceutical company’s decision to pursue research is difficult and complex. Resources are finite, so dollars and time are often devoted to projects that hold the most promise of making money to ensure the company continues to exist while also alleviating human suffering. This is an especially delicate issue when it comes to rare diseases, when a drug company’s investment could probably never be recouped because the number of people who would buy the drug would be small. However, in the case of developing a drug to combat river blindness, there were certainly enough people suffering from the disease to justify the research, but since it was a disease afflicting people in some of the poorest parts of the world, those suffering from the disease could likely not pay for the medication. In 1978, Merck & Co., one of the largest pharmaceutical companies in the world, was testing ivermectin, a drug for animals, to see if it could effectively kill parasites and worms. During this clinical testing, Merck scientists discovered that the drug killed parasites in horses that were very similar to the worm that caused river blindness in humans. For this reason, they wanted to engage in further research to determine if the drug could be adapted for safe use with humans to cure river blindness. This left Merck with a dilemma: the company’s scientists wanted the firm to invest in further research to create a drug that could cure river blindness, but the company knew it would likely never see a profit from such a product. Answer the following questions: 1. Who are the stakeholders in this situation? 2. What are the potential costs and benefits of such an investment? 3. If a safe and effective drug could be developed, it is likely that Merck will not recoup its investment. How could Merck justify such an investment to shareholders and the financial community? 4. If Merck decided not to conduct further research, how could it justify this decision to its scientists? 5. How would the media treat a decision to develop the drug or not to develop the drug? How might either decision affect Merck’s reputation? 6. Does Merck have an ethical obligation to proceed with the development of the drug? 7. If you were a senior executive at Merck, what would you do?

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