 CORRESPONDENCE Anesthesiology 2002; 96:1032 © 2002 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Too Limited a View of What Clinical Anesthesiology Could Become To the Editor:—Dr. Bernards’ conclusion that gene therapy may be in our future, albeit in a very limited way, may be based on too limited a view of what clinical anesthesiology could become. 1 For example, several laboratories in departments of anesthesiology are looking for new classes of biopharmaceuticals that target gene expression, not to mention viral vectors and other means of inserting novel genes, for the purpose of preconditioning vital organs that are likely to be jeopar- dized during pending surgery. How many of us could have foreseen the confluence of gene therapy and cerebral preconditioning 10 yr ago? And how many unforeseen applications of gene therapy in anesthesi- ology will be under investigation in 2011? Regarding Dr. Bernards’ argument that the economics of anesthetic drugs is such that drug companies will not be rushing to market with novel gene therapies for our use because the world-wide value of all anesthetic drugs is less than the value of the United States’ salsa market—if the application of gene therapy in anesthesiology were one-tenth the value of the United States’ salsa market we would have more salesmen in our offices than we have patients in our operating rooms. Besides, since when is anesthesiology a passive vessel whose progress depends on what drug companies market for our use? Clini- cians and researchers in anesthesiology delineate new problems, which define new needs, which generate new markets for new solutions. Pharmaceutical companies need our problems as much as we need their solutions. The relationship is synergistic, but it starts with us. A “why bother?” attitude toward gene therapy and the view that it may not offer clinical anesthesiology as much as it offers other medical disciplines could become a self-fulfilling prophecy. Anesthesiology would do better to view itself and gene therapy as endeavors whose combined and separate future application is unlimited. John Hartung, Ph.D., Department of Anesthesia, Downstate Medi- cal Center, Brooklyn, New York. jhartung@downstate.edu References 1. Bernards CM: Is gene therapy in our future? ANESTHESIOLOGY 2001; 94:947– 8. (Accepted for publication June 12, 2001.) Anesthesiology 2002; 96:1032 © 2002 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. In Reply:—Dr. Hartung makes several interesting points, although I find I cannot agree with them. His observation that “several laborato- ries in departments of anesthesiology are looking for new classes of biopharmaceuticals. . .” is probably an underestimate. Numerous de- partments, my own included, are involved in “gene-related” research that might someday have relevance to human pathobiology, but that is a far cry from these techniques becoming routine in the practice of medicine in general or anesthesiology in particular. In some ways, our differences of opinion on this point may reflect differences in our view of what constitutes the practice of anesthesia. Because Dr. Hartung is not a physician this is understandable. But, it is an unfortunate fact that anesthesiologists, particularly those in the United States, have largely (though not uniformly) withdrawn form anything but very short-term involvement with patients. This fact is sadly documented in a recent article in this journal that underscored the marked decrease in the number of anesthesiologists practicing critical care medicine. 1 Because gene-based therapies require longer- term (i.e., days to weeks or even life-long) involvement with patients it is unlikely that anesthesiologists will be routinely involved unless the unfortunate pattern of anesthesiologists withdrawing exclusively into the operating room environment reverses itself. This is not to say that we will not administer gene-directed drugs to our patients while they are in the operating room, but this is likely to be no more a part of the practice of anesthesia than is our administering an antibiotic before every surgical procedure. I also think Dr. Hartung’s suggestion that the availability of pharma- ceuticals for our use need not be dependent on pharmaceutical com- panies, and the financial aspects of drug development is a bit naïve (admittedly my view may be a bit jaded). The Orphan Drug Act exists because pharmaceutical companies would not produce some drugs that people need if they could not make money doing so. More directly relevant to anesthesiology is the fact that we have known since the 1970s that xenon may be superior to any other “volatile” anesthetic currently in use; but we do not have it for our patients because no pharmaceutical company can figure out how to patent an element and make money selling it. Too, fentanyl and sufentanil have never been approved by the Food and Drug Administration for intrathecal use, despite the overwhelming evidence that their use benefits patients, because no drug company sees a financial value in doing the necessary work to get them approved. Deep-throat’s admonition to Woodward to “follow the money” is as true when trying to figure out what pharmaceutical companies may choose to develop as it was in trying to understand what was going on in Richard Nixon’s Whitehouse. Like it or not, the financial aspects of pharmaceutical development will determine what gene-directed prod- ucts are available for our use. Dr. Hartung is correct that we can participate in the process by identifying problems that might benefit from gene-directed pharmaceuticals, but doing so will not guarantee that such products will come to fruition. Finally, I do not mean to suggest that my view of how this issue may evolve in the future is the preferred path. Rather, I sincerely hope Dr. Hartung’s view prevails. But I would be disingenuous if I said I thought he was correct. Christopher M. Bernards, M.D., Department of Anesthesiology, University of Washington, Seattle, Washington. chrisb@u.washington.edu References 1. Hanson III CW, Durbin Jr. CG, Maccioli GA, Deutschman CS, Sladen RN, Pronovost PJ, Gattinoni L: The anesthesiologist in critical care medicine: Past, present, and future ANESTHESIOLOGY 2001, 95:789 (Accepted for publication June 12, 2001.) 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