US Pharma Prices

'International Prescription Drug Price Comparisons: Estimates Using 2022 Data' (RAND Research & Commentary Research Reports 2024) by Andrew W Mulcahy, Daniel Schwam and Susan L Lovejoy comments 

 Understanding the extent to which prescription drug prices are higher in the United States than in other countries—after accounting for differences in the volume and mix of drugs—is useful when developing and targeting policies to address both growth in drug spending and the financial impact of prescription drugs on consumers. This report summarizes findings from comparisons of drug prices in the United States and other high-income countries based on 2022 data and presents results for specific types of drugs, including brand-name originator drugs and unbranded generic drugs, and from sensitivity analyses. 

Except for unbranded generics, manufacturer gross drug prices in the United States were substantially higher than those in other countries. Across all drugs, U.S. prices were 278 percent of other countries’ prices. 

U.S. gross prices for brand-name originator drugs were 422 percent of prices in comparison countries. 

After applying an adjustment for rebates paid by manufacturers, U.S. net prices for brand-name originator drugs were relatively lower but still over three times as high as prices in other countries. 

The United States had lower prices for unbranded generics than most countries. Unbranded generics accounted for 90 percent of U.S. prescription drug volume—a much larger share than the 41 percent for the comparison countries—but only 8 percent of U.S. prescription drug spending at manufacturer gross prices (compared with 13 percent in other countries). 

In contrast, brand-name originator drugs accounted for only 7 percent of U.S. prescription drug volume and 87 percent of U.S. prescription drug spending (compared with 29 percent of volume and 74 percent of spending in other countries). 

Overall, the United States' considerable unbranded generic market share and low average unbranded generic prices did not fully offset higher brand-name originator prices. ...

Understanding the extent to which prescription drug prices are higher in the United States than in other countries—after accounting for differences in the volume and mix of drugs—is useful when developing and targeting policies to address both growth in drug spending and the financial impact of prescription drugs on consumers. 

A prior RAND analysis compared 2018 manufacturer gross drug prices in the United States with those in 32 Organisation for Economic Co-operation and Development (OECD) countries using a price index approach. The earlier analysis reported results for all drugs combined, for specific categories of drugs, and under different methodological approaches. This report updates the main results from this earlier report using more recent data through 2022. It also includes new analyses focusing on price comparisons for biosimilars and changes in price comparison results over time. 

In brief, when analyzing data for all prescription drugs available in the United States and comparison countries, we found that U.S. manufacturer gross prices for drugs in 2022 were 278 percent of prices in the 33 OECD comparison countries combined. Put another way, prices in other countries were 36 percent—or a little more than one-third—of those in the United States. 

These results stem from the combination of starkly different price comparison findings for brand-name versus generic drugs: U.S. prices for brand-name originator drugs were 422 percent of prices in comparison countries, while U.S. unbranded generics, which we found account for 90 percent of U.S. prescription volume, were on average cheaper at 67 percent of prices in comparison countries, where on average only 41 percent of prescription volume is for unbranded generics. U.S. prices for brand-name drugs remained 308 percent of prices in other countries even after adjustments to account for rebates paid by drug companies to U.S. payers and their pharmacy benefit managers. 

These high-level findings from the current report are consistent with results from the prior analysis using 2018 data. Overall, the gap between U.S. and other countries’ prices widened slightly between the two analyses because of faster growth in U.S. prices, a change in U.S. drug mix, a change in the overlap of drugs sold in both the United States and other countries, or a combination of factors.

Ethics

“Just teach them the law!”: the ethics of value inculcation within legal education' by Alex Green in (2023) 57(3) The Law Teacher comments 

 To what extent should law teachers be permitted to advance controversial ethical, moral or political views as part of the LLB curriculum? This short paper grapples with that question by defending the ethical permissibility of such behaviour subject to the important proviso that it does not cause students “pedagogical harm”. In reaching this conclusion, three alternative views are considered and dismissed, each of which seeks either to eliminate value inculcation entirely or to restrict its scope to the moral-political values currently immanent within established law. The approach taken is argumentative, drawing upon analytical philosophy, with each contested and contestable view being presented in propositional form. Ultimately, it is concluded that value inculcation cannot be avoided within legal education and that, given this fact, the question becomes which values law teachers have a responsibility to advance. It is contended that this judgement, fraught though it might be for various reasons, is best left to individual teachers and that, for this reason among others, a permissive “no-harm” approach to value inculcation best justifies current pedagogical practices.

Birds and unconscionability

Edelman J in Productivity Partners Pty Ltd v Australian Competition & Consumer Commission; Wills v Australian Competition & Consumer Commission [2024] HCA 27 comments 

 The difficulty with the application of the values of Australian common law and statute is that they apply at such a high level of generality, and can point in so many different directions, that the concept of unconscionability has been said to be no more useful than the category of "small brown bird" to an ornithologist. In one recent case, three members of this Court considered conduct to be unconscionable where it involved a system of exploitation of illiterate and innumerate Aboriginal customers involving sales on credit at up to three times market value, without any proper accounting, with requirements of tied purchasing and the surrender of the customer's bank card and personal identification number. But four members of this Court considered that this exploitation of vulnerable persons from another culture took on a different perspective of conscience because, among other things, it was said that the conduct: was "appropriate" according to other cultures and values; was "a convenient way of managing money"; "suited the interests" of those vulnerable persons "and their families having regard to their own preferences and distinctive cultural practices"; and took place in a remote Aboriginal community where onerous terms were more "acceptable".

Section 22 of the Australian Consumer Law does not codify the values of Australian statute and common law, nor does it resolve such difficulties in application. Rather, it articulates a list of wide-ranging matters to consider when applying these values, including: the terms and conditions of the supply (ss 22(1)(b), 22(1)(e), 22(1)(j), 22(1)(k)); discrimination, undue influence, pressure, unfair tactics and the extent of good faith towards customers by the supplier (ss 22(1)(d), 22(1)(f), 22(1)(l)); conduct of the parties in connection with their relationship, difference in bargaining power and ability to negotiate (ss 22(1)(a), 22(1)(j)); the contents of any industry code (ss 22(1)(g), 22(1)(h)); and the ability of a customer to understand documents and the extent of any unreasonable failure of the supplier to disclose (ss 22(1)(c), 22(1)(i)). 

In applying the relevant values of Australian common law and statute, all matters and circumstances enunciated in s 22 that are potentially relevant must be considered. So too must any other circumstance that potentially bears upon standards of trade and commerce be considered. Otherwise, the assessment of conscience will have proceeded by reference only to a subset of the relevant values. However, contrary to the submissions of the College, the need for all relevant matters to be considered does not require an assumption that all matters weigh in favour of a supplier unless shown otherwise.

Academia

‘People look at you like you’re mad if you say good things about academia’: Collective Negativity, Anti-neoliberalism, and Hostility to Institutions in UK Higher Education – The Dark Side of Solidarity?' by Jessica Wren Butler in (2024) 6(2) Philosophy and Theory in Higher Education 257-280 comments 

Contemporary UK academia is riven with discontent: academics perform dissatisfaction on picket lines1 and social media, and higher education (HE) researchers internationally critique the so-called “neoliberal” university in which staff are over-worked, under-paid, over-managed, and under- valued.  Record numbers report a desire to leave the sector, and, curiously for a profession often characterised by ideals of independence and freedom,  academics position themselves as disempowered, ‘besieged’, and ‘under attack’. 

While critics of modern academia point to a ‘competition fetish’instilled by recent developments in HE policy and argue that compared to a collegiate past the present climate of universities is one of ruthless individualism, this perception of atomisation sits uncomfortably alongside the collective eschewal of neoliberal and managerialist ideologies. If there is space for solidarity in academia, its common ground appears to be dissatisfaction, negativity, and vocal disavowal of contemporary trends. 

This article considers the implications of such complaint, arguing that belief in the toxicity of neoliberal academia and a corresponding romanticised investment in a ‘golden age’ of HE have become required thinking for those wishing to be ‘part of the club’ (Participant 18).Drawing on interviews with academic staff in English higher education institutions (HEIs) in 2018 I demonstrate the ubiquity of a particular version of “critical thinking” as an idealised academic trait and suggest that, regardless of the legitimacy of the criticism, the need to visibly communicate disavowal of “the neoliberal academy”, particularly through hostility towards institutions and those who play managerial roles within them, risks perpetuating a joyless and exclusionary environment.  While I do not wish to deny or defend many aspects of con- temporary academia, I do seek to complexify the conventional groupthink around this topic and suggest that the logical extension of certain arguments against supposedly “neoliberal” moves take us not towards a utopian future but a regressive past. 

I begin with a brief description of the underpinning research before mov- ing to consider neoliberalism as a concept, evaluating its meaning and utility as context for my argument that academics’ anti-neoliberal critiques of HE may not be as productive as intended. I then briefly summarise what is meant by “the neoliberal university” in order to clarify the types of policies, processes, and practices deemed problematic. Finally, I suggest that valorisation of critical thinking results in a collective thought pattern around contemporary UK HE – namely that university management, as a metonym for the institution (and the wider construct of “the neoliberal university”), are suspect. I conclude that the prevalence of this belief and its normative status, especially when epitomised through group action such as union strikes, may promote solidarity between (some) academics, but at a cost. Every collective act also contains tensions, contradictions, and exclusions, which may go unexamined when the prevailing ideology is believed to be underpinned by the progressive and socially liberal ideals many participants saw as emblematic of academics’ politics.

CryoRisks

'Life-Suspending Technologies, Cryonics, and Catastrophic Risks' by Andrea Sauchelli in (2024) 30 Science and Engineering Ethics comments

 This paper explores one way of empowering future generations by giving them causal efficacy over at least some members of their previous generations. Such an empowering, I argue, would be beneficial, as it contributes to diminishing a catastrophic and existential risk factor, namely the expressions of insufficient concern that some present influential individuals and institutions demonstrate towards the welfare of future people—a form of what I call ‘generational egoism’. The type of technology analysed in this paper, which would reduce the temporal parochialism of the present generation, can be characterised as a life-suspending or life-extending technology, and cryonics is one of the most well-known examples. 

Although this essay focuses on the risks posed by climate change, I find it useful to deploy the broader concepts of ‘catastrophic’ and ‘existential risk’ to discuss the range of benefits related to cryonics or other relevantly similar life-suspending technologies. The reason is that such technologies may mitigate not only climate change-related risks but also risks of a broader and more heterogeneous category, namely, those risks related to some present individuals’ or collectives’ lack of (sufficient) concern for future people. More specifically, my argument includes the claim that in the case of certain catastrophic and existential risks, a general attitude—a form of generational egoism—is at least a risk factor, where a risk factor is something that causally increases the likelihood of a risk (see final appendix). In the case of an attitude or motivation being a risk factor, I will mean that such an attitude or motivation underlies actions increasing the likelihood of certain risks. However, under specific circumstances, some features of this attitude can become a security factor (i.e., something that causally decreases the likelihood of a risk). Cryonics or other similar life-suspending technology, which can give rise to such circumstances, may thus be considered a security factor for at least certain catastrophic and existential risks or risk factors. If I am right, insofar as we are interested in promoting what is beneficial to humanity, we would have a good (defeasible) reason to invest more widely in developing and making more available such technologies. 

Unfortunately, at least in the academic philosophical literature, the ethical and practical impact of such technologies seems to be severely under-researched. I think that this is unfortunate and that, since life-suspending technologies would be extremely beneficial to humanity, they deserve more discussion. This paper is structured as follows. The first section briefly introduces the notions of catastrophic and existential risks. The second section of the paper clarifies what is meant by ‘cryonics’. The key aspect of cryonics relevant to this paper is that it may allow people existing at a certain time to somehow recommence or restart their lives at a later time, perhaps even significantly later (e.g., at a time significantly distant temporally from when they started the procedure). I wish to emphasise that cryonics (1) is here discussed qua life-suspending or life-extending technology—any other technology with the same functions would play the same theoretical role in this paper—and (2) need not be understood as a technology primarily intended to enable humans to achieve immortality. Even if we could never become immortal or everlasting, we would still have reasons to develop and make life-suspending technologies widely available. The third section outlines the general argument that cryonics is a security factor for a heterogeneous set of catastrophic and existential risks. The fourth section focuses on one of these risks: climate change. In the same section, I articulate in more detail some aspects of the problem of climate change that relate to its intergenerational character and that would be mitigated by the widespread use of cryonics. Some objections are then discussed in the final section.

Territories

'Ships of State and Empty Vessels: Critical Reflections on ‘Territorial Status in International Law’ byAlex Green in (2024) Oxford Journal of Legal Studies comments 

In his recent monograph, Territorial Status in International Law, Jure Vidmar offers ‘a new theory of statehood’ that consolidates his existing work and departs in important ways from legal orthodoxy. As a work of doctrinal law, the text is rigorous; however, its theoretical contribution is somewhat unclear. Vidmar’s central theoretical claim—that the status of individual states is established by discrete norms of customary international law—adds very little to his doctrinal argument. By examining his position, this review article examines what it might mean to provide helpful ‘theories of statehood’. It begins by framing the theoretical challenge posed by such work before setting out some desiderata for theoretical success in this area. Finally, it sketches out a general approach, grounded in Hannah Arendt’s conception of power, which offers a promising means for moving beyond doctrinal description within ‘reconstructive’ international legal theory. 

States are among the most powerful subjects of international law, not only in terms of their economic, military, political and social capacities, but also insofar as that legal order characteristically grants them a broad range of important immunities, liberties, powers and rights. These include, for example, the right to political independence, permanent sovereignty over natural resources and immunity from compulsory jurisdiction before international courts and tribunals. Moreover, for those who consider states to be necessarily territorial entities, their existence is intertwined with the presence of legally delineated physical spaces, in terms of which that existence must be identified and explained. Despite the centrality of both statehood and territory within doctrinal law, questions concerning their nature are some of the more complex and controversial within international legal theory. In his new book, Territorial Status in International Law, Jure Vidmar grapples with this complexity, seeking ‘a new theory of statehood’ by conducting an international legal analysis of territory in general. 

Vidmar makes this offering within an increasingly crowded field. There is a huge quantity of doctrinal and theoretical work on both statehood and territory, encompassing legal scholarship, political philosophy and the history of international relations, as well as interdisciplinary contributions across these fields. Given this, it is somewhat odd that Vidmar claims there to be a ‘paucity’ of scholarship on the legal nature of statehood. There are nonetheless a great many things to recommend his new monograph, which mirrors the meticulous doctrinal analysis of his earlier book, Democratic Statehood in International Law. It is refreshing to see mainstream legal work which critiques some distinctions between state and some non-state entities, as well as to see an analysis of statehood that goes well beyond the archetypal citation of article 1 of the 1933 Montevideo Convention on the Rights and Duties of States (‘the statehood criteria’, to use Vidmar’s phrase). Vidmar also gives detailed attention to the territorial and statehood-related elements of several contemporary and controversial international conflicts, such as that between the State of Palestine and the State of Israel, as well as between the Russian Federation and Ukraine. 

Notwithstanding the outstanding quality of this work, I disagree with Vidmar’s doctrinal analysis on a number of points. He alleges, for example, that several entities, including the Republic of Kosovo, Palestine and the Republic of Somaliland, do not possess statehood: on this we differ. Similarly, he disagrees with both Rowan Nicholson and myself about whether ‘effectiveness’ provides a basis for state creation—an orthodoxy that Vidmar completely denies. My focus in this review article, however, is not the detail and controversy of these doctrinal views, but rather the theoretical approach that Vidmar takes when seeking to elucidate them. In particular, what interests me is the question of what it means to provide a ‘theory of statehood’ and in particular what desiderata for success such a theoretical exercise might assume. At bottom, and despite his claims to have done so, I remain sceptical that Vidmar provides us with anything like a theory of statehood with Territorial Status in International Law, although that text does perform valuable work in clarifying several points about the legal concept of territory. 

To advance my argument, I begin by outlining three sets of questions one may wish to ask about states (section 2), before considering what desiderata a genuine theory of statehood would have to satisfy in order to qualify as a successful legal-theoretical contribution (section 3). Throughout both discussions, I highlight important contributions that Vidmar makes towards our understandings of both, as well as pointing out places in which his reasoning and conclusions fall short of the ideal. Having completed this task, I then sketch a theoretical approach to legal statehood that might satisfy the desiderata I identify (section 4). Although necessarily provisional, this sketch illustrates how an interrogation of statehood that employs non-positivist ‘rational reconstruction’ might yield more theoretically promising results than ‘black letter’ doctrinal analysis alone.

Disasters

The Senate Select Committee on Australia’s Disaster Resilience 'Boots on the ground: Raising resilience' report features the following recommendations 

Recommendation 1 

The committee recommends that the Disaster Recovery Funding Arrangements and relevant guidelines be amended to enable funds to be distributed for the purpose of building betterment into recovery and reconstruction, ensuring that this funding is available to all jurisdictions. 

Recommendation 2 

The committee recommends that the Australian Government establish a national asset register to improve the efficiency of the deployment of resources in the aftermath of a disaster. The Government should consider whether it is feasible to include not only federal and state government assets, but also suitable local community, private sector and non-government organisation assets. 

Recommendation 3 

The committee recommends that the Disaster Recovery Funding Arrangements be amended to set aside a proportion of funding to be offered to local governments up-front to help facilitate disaster recovery and resilience to ensure councils do not always have to bear the burden of financing repairs up-front. 

Recommendation 4 

The committee recommends that the Australian Government consider amendments to the Fair Work Act 2009 to legislate time off for volunteers working with registered organisations and for volunteers to be granted leave from employment, similar to the provisions provided to Reservists under the Defence Reserve Service (Protection) Act 2001. 

Recommendation 5 

In circumstances where the cost of relevant training is not covered by the organisation, the committee recommends that the Australian Government consider amendments to legislation, policy and guidelines to allow volunteers working in organisations such as State Emergency and Rural Bushfire Services to claim tax deductions for training and courses that are a part of their emergency volunteering. 

Recommendation 6 

The committee recommends that the Australian Government establish a national disaster mental health hub to coordinate and provide mental health resources, training, and support for first responders and communities xiv affected by disasters across the nation. This hub should serve as a comprehensive resource centre for addressing the mental health needs of all stakeholders involved in disaster response and recovery efforts. 

Recommendation 7 

The committee recommends that the Australian Government design and implement consistent national trauma-informed care principles, ensuring that first responders—both professional and volunteer—receive training and support in these national principles to better address the mental health and well-being of disaster-affected individuals and communities. 

Recommendation 8 

The committee recommends that the Australian Government convene a disaster resilience mental health summit to hear from all related agencies and stakeholders to identify solutions to the mental health impacts of disaster. 

Recommendation 9   

The committee recommends that the Australian Government consider how it can further support Disaster Relief Australia, and other similar organisations, not only with funding beyond 2026, but also how the Australian Government can further incorporate Disaster Relief Australia into its national disaster response arrangements and boost its numbers through partnerships with the Australian Defence Force and the Department of Veterans’ Affairs. 

Recommendation 10 

The committee recommends that the Australian Government consider ways to incentivise young Australians to participate in volunteer organisations that provide support for disaster response and recovery.

Publicness

'The Impoverished Publicness of Algorithmic Decision Making' by Neli Frost in (2024) Oxford Journal of Legal Studies comments 

The increasing use of machine learning (ML) in public administration requires that we think carefully about the political and legal constraints imposed on public decision making. These developments confront us with the following interrelated questions: can algorithmic public decisions be truly ‘public’? And, to what extent does the use of ML models compromise the ‘publicness’ of such decisions? This article is part of a broader inquiry into the myriad ways in which digital and AI technologies transform the fabric of our democratic existence by mutating the ‘public’. Focusing on the site of public administration, the article develops a conception of publicness that is grounded in a view of public administrations as communities of practice. These communities operate through dialogical, critical and synergetic interactions that allow them to track—as faithfully as possible—the public’s heterogeneous view of its interests, and reify these interests in decision making. Building on this theorisation, the article suggests that the use of ML models in public decision making inevitably generates an impoverished publicness, and thus undermines the potential of public administrations to operate as a locus of democratic construction. The article thus advocates for a reconsideration of the ways in which administrative law problematises and addresses the harms of algorithmic decision making. 

The use of algorithmic—including machine learning (ML)—models in public decision making to assist or replace human administrators in their routine decision-making tasks, has garnered much attention in recent years. Scandals such as the ‘Robodebt Scheme’ in Australia or the childcare benefits scheme in the Netherlands offer stark examples of why legal scholars are increasingly concerned by this use. From a legal standpoint, such use may certainly contribute to vital features of a properly functioning public administration, such as efficiency, expediency (together referred to as ‘scalability’) and ‘Weberian instrumental rationality’. But it also potentially undermines both ethical and legal principles that are decidedly significant in this arena, such as fairness, due process, the rule of law, a range of human rights and principles of justice, as well as individual autonomy or dignity. Concerns that centre on these principles all meaningfully problematise the use of algorithmic models in public administration. Algorithmic decision making is indeed often biased, is typically opaque and unexplainable, and can result in unjust, rights-infringing decisions at least some of the time. 

The present article joins these concerns, but offers a different, complementary frame to problematise the use of algorithmic models—particularly ML—in public administration. Broadly preoccupied with the tensions between novel technologies and democracy, this frame centres a unit of analysis that is constitutive of the very idea and fabric of democracy: the ‘public’. The article grapples with the following interrelated questions: can ML-driven public administrative decisions be truly ‘public’? And, to what extent does the use of ML models compromise the publicness of public decision making and decisions? These questions are part of a broader inquiry into the myriad ways in which digital and artificial intelligence technologies transform the very fabric of our democratic existence by mutating the ‘public’. 

The main claim I advance in the article is two pronged. First, I offer to view public administrations as important sites of democratic construction insofar as they maintain a quality of publicness. To make this argument, I offer a theory of publicness that is tailored to the arena of public administration, and explain the importance of this attribute for the potential of bureaucracies to function as coherent entities in modern democratic states. Secondly, I argue that the increasing deployment of ML technologies compromises the publicness of administrative decision making and decisions to generate an impoverished publicness and thereby destabilise this site’s democratic potential. 

Together, these two prongs contribute to thinking in the fields of law & technology, public law theory & democratic jurisprudence and administrative law. To the first, the article cautions that the challenges that it identifies are likely to persist even where technological advancement will allow the overcoming of concerns that relate to the bias and opaqueness of ML models, which currently occupy much of the literature. To the second, it offers a view of publicness that complements parallel treatments of this concept, but that is tailored to the specific site of public administration and its unique features, and is also well suited to address the challenges that bureaucracies face today in the advent of technological developments. To the last, it highlights administrative law’s existing limits in fully addressing the plights of algorithmic decision making, and points to novel sites for regulatory intervention. 

The arguments the article puts forward unfold as follows. Section 2 addresses the first prong of the argument. It theorises what publicness means in the context of public administration—as both a norm and an institutional practice. Publicness in this account centres on the web of interactions between public administrators themselves and between them and the public’s elected representatives. It is theorised as an attribute that relates to public administrations’ praxis of decision making and to their decisional outcomes. Briefly, it is grounded in a view of public administrations as ‘communities of practice’ that operate through dialogical, critical and synergetic interactions driven not only by explicit knowledge, but also by tacit, practical forms of knowledge. Publicness is further grounded in the view that this unique feature of the fabric and operations of public administrations potentially allows them to track—as faithfully as possible—the public’s intricate view of its interests and to produce decisions that reify those interests. 

This theory of publicness is grounded in a theory of democracy that explains its normative value. The normativity of publicness lies in the claim that it imbues public administration—that unelected, democratically suspect stratum of state functionaries—with democratic legitimacy by institutionalising the neo-republican ideal of liberty as non-domination within the bureaucracy. Publicness is also grounded in a theory of the state that helps frame its ontology. I draw here on the work of Martin Loughlin, and his account of power, politics and representation, to explain the political and institutional constraints in which public administrations operate and which shape their task of governing. Importantly, my concept of publicness is equally grounded in empirical accounts of how public administrations operate in practice, which demonstrate its plausibility. I draw here on literature in both law and political science that empirically examines the nature of interactions between public administrators themselves and their interactions with the public’s elected representatives. 

The article then proceeds in section 3 to address the second limb of the argument that problematises the use of ML models in public administration. I begin here by situating the claim in the broader literature on algorithmic public decision making, and offer an overview of the types of normative concerns that have attracted legal scholars’ attention in this context. I then move to offer a different problematisation that draws on my analysis of publicness and the necessary conditions for its viability. Here, I suggest that the use of ML models in public administration is malignant to the operations of communities of practice. The claim, in brief, is that the knowledge and operational logic of ML models is largely incompatible with the types of knowledge and interactions that drive communities of practice. ML models thus undermine the quality of publicness, so that public decision making that incorporates these models will feature an impoverished publicness. On this account, publicness is not only deeply political, but also deeply human. I conclude with the observation that if this is the case, the analysis of publicness should inform how we shape the law that regulates ML systems.