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Mon January 27, 2014
The Ethics of Preventative Medicine
I just returned from a seminar for reporters on covering what may come next for the Affordable Care Act. One of the last sessions was a talk by prominent bioethicist Art Caplan, new head of the NYU Langone Medical Center's Division of Medical Ethics (you can read more his illustrious career here).
Caplan was talking about some of the ethical "land mines" ahead for the ACA. And they weren't what I thought. For instance, Caplan called into question one of the law's central tenets: prevention as cost containment.
The law requires insurance companies to cover several "essential" health benefits, including many preventative services, like physicals and prenatal care. Health officials in Rhode Island talk a lot about the value of preventative medicine in terms of keeping people healthier and managing chronic diseases. The concept: prevent chronic diseases like diabetes from developing now (with lower cost interventions like regular check ups, weight management, and nutrition counseling) and you avoid the costlier interventions (like hospital stays and surgeries) down the road if diabetes develops and goes unchecked.
Makes sense, right? Spend a little now to save a lot later?
But Caplan kind of blew my mind when he told us that prevention might not be so cost effective for society overall. He pointed out that nutrition counseling, posting calorie counts on restaurant menus, and seeing a doctor for regular physicals (at which he or she tells you to lose some weight) don't necessarily change a person's behavior. And even if we do live longer, healthier, higher quality lives, by the time we get old, we might still be costly to the system. Older people develop debilitating, costly diseases like Alzheimers. A huge percentage of our medical dollars are spent in the last 60 days of life.
I argued that if you arrive at old age healthier, won't you still cost the system less than if you make it to your 70s or 80s with chronic obstructive pulmonary disease or morbid obesity? Caplan's argument was that most people won't make those kinds of healthy changes, and that diseases of old age are going to be costly. Rather, he said, for argument's sake, let people engage in risky behavior and die sooner, saving in overall costs to the system.
Caplan isn't an evil, dark cynic. He was simply raising the ethical question, and questioning the assumption that prevention will solve all of our cost problems.
What do you think? I'd love to hear your take.