When Moral Hazard is the Safest Course

Patheos blogger Thomas McDonald of God and the Machine is horrified by the FDA’s recommendation to approve Truvada (an antiretroviral cocktail) as preventative treatment for HIV.  When people use the prophylactic regime, their chances of contracting HIV are reduced by 50-75%.  As far as I can tell, these are the ‘actual use’ numbers.  With perfect use, the chance of infection goes down to pretty much zero.  This is why, in affluent countries with good health care services, there’s virtually no chance that a HIV+ mother will pass on the infection to her child; we’re pretty good as sticking to perfect use in those circumstances.  When Truvada was tested in clinical trials as a prophylactic, it was so effective, that the experiment had to be ended early, as it would be a breach of medical ethics to deny the patients in the control group access to a life-saving drug.

McDonald is worried that the doctors are thinking only about pharmacological efficacy, not behavioral changes and moral hazard.  He writes:

I searched in vain for some indication that the authors of the Stanford study understood the psychological effect of giving sexually active, highly promiscuous gay men the idea that they’re essentially invulnerable, and the radical increase this will cause in high-risk behavior: an increase that must certainly offset the drug’s effectiveness. Any drug that is less than 100% effective stands a very high chance of creating more problems because it will lead to an increase in dangerous behavior.

The FDA approval for this use of Truvada is irresponsible, since it will push Medicare, Medicaid, and the insurance companies to cover the drugs for PrEP purposes, adding a huge new burden to the already-strained healthcare system. This means that men who don’t have HIV, but wish to engage in high-risk sexual activity, will be playing Russian roulette with a drug that doesn’t even work half the time.

I understand the horrors of death by AIDS. I had the misfortune of seeing it up close with someone I loved dearly. But our desire for a solution to this scourge shouldn’t cloud our common sense. New HIV infections are 100% preventable, but the solution is not chemical: it’s behavioral. That’s been the hard truth at the heart of this epidemic from the beginning.

A lot of health care policies make people queasy in the exact way that McDonald describes.  HIV-prevention is especially politically and culturally charged, since it was an enormous struggle to get the health care field to make treatment of ‘the gay disease’ a priority in the first place, but these objections crop up all over.  The reason is simple, almost all health care increases moral hazard, since the point of medicine is to lower the costs of being sick.

We get accustomed to a lot of the ways we make being sick easier, so we only respond with revulsion to new treatments or to programs that make life easier for people whose behavior we strongly oppose.  Look at two other examples:

In Vancouver, the city has set up a safe injection site for drug users.  There is sterile medical equipment free for the asking, there are nurses who will help you find a vein (but will not insert the needle), there are paramedics in case of overdose, and there are counselors who try to persuade users to enter rehab.  It definitely sounds like an addicts paradise.  Here’s the thing, it works.  HIV infection rates have plunged among the drug using population, violence is down, more people have an entry point for help if they ask for it.  But very few cities have followed Vancouver’s lead, because no one wants to do something nice for drug addicts unless we also get to make them stop being drug addicts.

In St. Paul, homeless alcoholics who have repeatedly failed out of rehab facilities can enter the St. Anthony Wet House.  They are allowed to drink the alcohol they buy, but they don’t do it on the streets.  Their alcoholism is still killing them, but it’s less likely that they’ll die of exposure or pneumonia or in a fight over their stash with another homeless person.  So the wet house doesn’t solve the root problem (but nothing else has so far), it just lets them drink themselves to death more slowly and with more dignity.  Again, this intervention is seldom adopted because it improves outcomes without condemning or addressing the root problem.  The fact that we have no treatment that has proved effective is irrelevant to people’s feelings; they need some way of registering that they disapprove.

Unlike McDonald, I think same-sex relationships are morally neutral, so aiding and abetting them isn’t a problem for me.  (I’ve got more qualms about hookup culture and promiscuity, whatever the match-up).  But even granting some of his premises, I can’t believe that the right way to approach sexual ethics is to just make it much more risky and deadly.  The FDA recommends Truvada because it’s better for the people taking it on net.  That means the moral hazard of more sex is outweighed by the lower transmission rates, even factoring in more sex.

That means you’d better be really confident that it’s worse for people who are engaged in behavior you condemn to be healthier than to be sick.  You’d better have data that makes it clear that their suffering will actually motivate a change in behavior (and, in this case, you need to persuade people that homosexuality is harmful in the first place).  Otherwise, like the people who reject Vancouver’s safe zone for drug addicts, you sound like you’re really trying to restore some kind of cosmic balance, where people who do bad things need to have bad outcomes, even if we have the power to protect them.

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  • Jaymin

    We should also prohibit seatbelts. I hear they encourage the risky behavior of driving, which so very often leads to accidents.

  • Slow Learner

    Jaymin, I was reminded of that; though more specifically the suggestion of placing a spike on the steering wheel, so that people would really have an incentive to drive carefully!

  • I made sure I separated the two main issues here. I called reducing disease transmission a “moral good.” It’s irrelevant whether I approve or don’t approve of the activity in question: protecting the human individual from disease is always a moral good. The second issue, of course, is the activity in question, which is not “good.” I think Benedict’s point about a male prostitute who uses a condom to protect a human life holds here: it shows a moral awareness of the preciousness of all life. A person isn’t condemned to death because of a poor moral choice.

    However, I want to draw the focus back to my main point, which you seem to be downplaying: that is, the psychological effect of the drug. I’ve seen some studies showing very high rates of success with perfect use, but these are small, controlled studies where people are well-instructed and monitored. When the drug makes its way into general use, several major problems arise.

    First, if people feel they are “protected” against HIV, they will be less cautious and in engage in more high-risk behavior. How does this increase in high-risk behavior offset the effectiveness of the drug? I’m not at all assured by studies that show effectiveness as low as 44%, and by focusing on the higher effectiveness rate, you seem to be downplaying this very real risk.

    Second, the drug can be extremely toxic. It requires constant monitoring and can damage the user’s health, which brings us to the third point: the drug is being taken as a hedge against lethal disease so that people can engage in high-risk sexual activity. I take a potentially lethal drug so I can walk and use my hands. I know others who take potentially lethal drugs so they don’t die. Obviously, we have a different perspective on this issue, but drugging yourself (at no small expense to the State and the insurance companies) so you can engage in certain sexual activity seems like madness, and making others pay for it is doubly so.

    • By the way, I’m not seeing this one: “almost all health care increases moral hazard, since the point of medicine is to lower the costs of being sick.”

      There’s no increase in the moral hazard from me taking Humira, since it just suppresses my arthritis, or from my father’s cancer treatment, since it just keeps him from dying. I feel like I’m missing part of your point here.

      • leahlibresco

        Any disease that has a behavior risk factor (which is a lot of them) has that behavior get less risky the more effective the intervention is. Cholesterol medication gives me a little more leeway in what I eat. Readily available antibiotics and flu vaccines mean I can be more lax about handwashing and other hygenic concerns. These treatments are pretty effective, but, at the margins, there’s probably some people who will be worse off because of the reforms that make us on net safer.

        • Okay, I agree with that. I think your characterization of it as “almost all health care” in relation to behavioral risk factors is overstated, but your examples are good. Certainly, there was no behavioral risk factor in my own illness, or in my son’s asthma or asperger’s, or many other illnesses. These are out of our control.

          The problem in citing “net safety” is that we better be a lot more sure about the “net” part. I don’t think Truvada’s there at all, and I think the dynamics of this particular combination of drug, disease, population, and behavior has a lot of variables that bear further study before it enters widespread use.

          • leahlibresco

            Dan Savage shares your concerns. I’m inclined to guess that people who can’t be bothered to use condoms won’t seek out a prescription for a drug with unpleasant side effects, so the group that actually makes an effort to use it will be more likely to use it correctly.

            There are ways to roll out this drug badly, but there are populations that are very motivated to use it well (serodiscordant monogamous partners, for one). I’m glad the FDA is broadening its use beyond pregnant women, and I think they’ve got the capacity to do more good than harm. To my knowledge, the clinical trials found that the benefit exceeded the behavioral cost.

    • Ken

      I am totally not getting the moral relevancy argument here. We have a drug that can effectively reduce AIDS numbers, but because some people will abuse the resultant sexual freedom, we should not use it? And just how much does AIDS treatment cost vs. the use of this drug? Has the Hippocratic oath been completely discarded? Simply eradicating this disease from the planet, like we thought we had with smallpox, would be morally significant, even if a few gays were to see it as a license for one night stands every night. Oh yeah, smallpox is once again a concern because a few nutjobs refuse to subject themselves to the carrier fluids used in the vaccine. So, we should just live with the pain and suffering and death of a disease because, well, “certain people” will think they can have sex whenever they want with whoever they want? Um–I think McDonald is a Xian troll on this one, whether he knows it or not. Just imagine how people would brush their teeth more if we did away with Novocain — for their own hygienic good, of course.

  • keddaw

    I don’t want to impute TLM’s motives, but it seems to parallel the Christian right’s demand to deny contraceptives and sex-ed to teenagers as the dangers of getting pregnant (with no abortion!) are enough to stop those pesky kids having sex. (The wages of sin?)

    • Maiki

      It makes sense if you think the problem is not “kids getting pregnant” but “kids having sex”.

    • Brandon

      I think imputing his motives is entirely fine. His entire point looks like nothing more than a long rationalization of “bad behavior needs to be punished”.

  • Alex Godofsky

    “Almost all health care increases moral hazard, since the point of medicine is to lower the costs of being sick”

    To quibble, this only happens if the sick person doesn’t pay the price of the medicine. Right now we feel obligated to provide existing medical treatments to people regardless of their ability to pay. McDonald’s argument works out to “we shouldn’t research a cure for this disease, because then we’ll feel obligated to provide that cure to everyone. The only way to control our generous impulse is to avoid developing a cure at all, so we won’t feel guilty when we can’t provide it.”

  • anon atheist

    You are right when you further down in the OP say that this is a matter of assessing the consequences whether the reduced risks outweigh increased risk taking.

    But I doubt that the FDA has thoroughly done that. First of all I doubt that the FDA has actual data on that. And secondly consider this. One year of Truvada costs 10,000 $. One quick HIV blood test costs if you buy in bulk less than 5 $. This means if have your partner do a test beforehand which would lower your risk at least as much as Truvada you can have 2000 times unprotected sex in a year until the break even. So why is the FDA indirectly advocating a measure that is so much more expensive?

    • leahlibresco

      HIV tests lag about 6 months behind your actual infection status. Even partners who are monogamous and both test negative should wait at least 6 months after a negative test and test again to confirm the initial result before giving up condoms. [/public health advisory]

      • anon atheist

        HIV test lag a maximum of 3 months behind your actual infection status. But usually an infection shows up after 6 weeks. And there are newer test that can pick up an infection within the first couple of weeks as well.

    • Brandon

      But I doubt that the FDA has thoroughly done that. First of all I doubt that the FDA has actual data on that.

      Are you under the impression that FDA regulators have failed to think of something that’s so obvious that it’s occurred to multiple bloggers?

  • I think it should be noted that there’s a self-interest motivation as well. Even if I’m not having promiscuous sex, there are lots of reasons why I might want less dangerous blood-borne viruses out in the wild. If potentially helping people safely engage in a behavior I don’t personally approve of makes the world a less dangerous place for everyone, including me and mine, then I don’t really see the problem. HIV is no more restricted to the promiscuous than it is to homosexuals. “More at risk” does not mean “don’t do this or be a part of this group and you’re totally safe forever.”

    Also, I think it’s reasonable to say that those who are promiscuous do NOT deserve to die slowly of a disease we could have prevented, just because we don’t approve or don’t want to pay for their preventative treatment. That sounds an awful lot like maintaining a passive (and rather indiscriminate) death penalty for a “moral crime.” I find that highly objectionable. If the treatment doesn’t work or is toxic to the point of doing more harm than good that’s one thing, but that doesn’t seem to be the core objection here.

  • Maiki

    Hey, I don’t mind this advances. Maybe we can have conversations about the morality of contraceptives as separate from the morality of prophylactic medicine, especially as the meds get cheaper in the future.

  • I think drug addicts including alcoholics are a special case so the analogy is off.

    Addicts have impaired freedom of will so their actions are in some sense closer to natural disasters than to moral actions. And if we don’t know to prevent the disaster it makes sense to focus on alleviating the consequences.

    But we don’t feel that way about actual free actions. I’d be a lot more squeamish about safe injection sites if they were used by first time users, who wanted to try the drug out in a safe environment. And, to pick a much more extreme example, we surely don’t offer quick and painless poisons to people who would otherwise murder with slow and painful household chemicals. Alleviating the consequences of compulsions doesn’t make us into accessories the way alleviating the consequences of chosen actions does.

    Now one could say that having gay sex with more than five different dudes a year falls closer to the unchosen end of the continuum. That would match the standard rhetoric about how being gay is not a choice and separating desires and actions doesn’t work. But if you want to extend that to full-on promiscuity (which I won’t, because I don’t buy the identity of desire and action in the first place) I could only see that as proof of gayness actually being a mental disease.

    Illustratory thought experiment: Suppose a compulsively promiscuous gay man* took the prophylactic and still got infected. If he had the choice, harming other people is different from harming himself so we must charitably presume he will now do the right thing. But if we presume him literally unable to not be promiscuous we would have to presume he will go on in that way which makes him a lethal danger. So would you support quarantining everyone for whom the prophylactic fails? I think the obvious answer is no, but that means his actions are actual moral actions.

    *I’m talking specifically of men because the drug doesn’t work for women.

  • A complication that sometimes does not enter the discussion is “Who pays?”
    I think it is more fruitful to discuss the “Ethics” of the choice of drug/treatment use in two scenarios:
    (1) The individual must pay
    (2) The government takes money from some 1/2 the population to pay for this treatment to those who don’t contribute.

    Often times, the “Ethical” conclusion of those two scenarios don’t agree — then the real problem becomes obvious.
    If they agree, everything is good. But that is rarely the case.

  • SAK7

    If the actions of the promiscuous were to bring consequences only upon themselves, we’ve one set of facts and moral arguments. In this case under review, there is a very real threat that the belief of impunity will result in multiple exposures to innocent third parties. TLM’s argument is valid.

  • Since ethics and approaches making ethical decisions (in contrast to the decisions themselves) are major topics here, I’m going to suggest people go take a look at today’s Experimental Theology (http://experimentaltheology.blogspot.ca/2012/05/orthodox-alexithymia.html) on the roles of reason and emotion in decision-making. I’m seeing contrast; specifically, Beck sees as a problem the logical rhetoric of “swallowing” moral squeamishness in the face of reason, because reason is finally incapable of making decisions (psychologically speaking). Emotion is necessary to decision-making processes. This sounds a lot like that quote from Less Wrong that people bandy about regarding gritting your teeth through logical self-scrutiny. How can we tell the difference between instances in which gritting ones teeth is better and instances in which the final emotional check is better (and what would be the metric for “better”)?
    Pertaining to this, my immediate reaction is that any reasoning that allows people to die because it’s looks logical is a symptom of Beck’s orthodox alexithymia.

  • @b

    TM’s argument is that the FDA is ignoring his studies that conclude that in the wild Truvada won’t decrease infections. Has the FDA seen those studies? found them uncompelling? If so, then they’re acting on the scientific consensus known at the time, so I don’t see how their approval of Truvada can be ethically impermissible (even if that concensus eventually turns out to be mistaken).