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.