Tuesday, February 06, 2007

HPV, Rationing, and Health Ethics

Cervical cancer is a serious problem. In 2007, it is estimated that 11,150 cases will be a reported in the United States, resulting in the death of 3,670. Those affected by cervical cancer are disproportionately women of color and low-income women (not to mention the large problem internationally in the developing world). However, between 1955 and 1992, the number of cervical cancer deaths in the United States dropped by 74%; the main reason for this change is the increased use of the Pap test.

Merck's HPV vacine Gardasil was recently approved by the FDA and is being marketed to young women. I support the vaccine. However, I believe greater consideration is needed when deciding whether or not this should be a mandatory vaccine for school-age girls. Typically, religious fanatics are the ones arguing against universally administering the vaccine. That is not me; I am merely asking for greater contextualization of this vaccine in the health system.

Texas recently mandated that girls in the sixth grade receive the HPV vaccine. This treatment costs $360/person. When taken as a whole, this will cost the state of Texas $60 million dollars. Of course, any sum of money to prevent cervical cancer in women is "worth it." However, is this the best use of 60 million dollars? Texas represents about 8% of the U.S. population. With extrapolating, this means $60 million dollars will be used to prevent around 900 cases of cervical cancer, or around 300 deaths.

I admit, calculations such as these are cold and heartless. They make me uncomfortable. I don't like to make such statements. I want to to say that any vaccine to prevent a terrible disease is well worth it. But it some ways, not thinking about the alternatives is heartless. Tradeoffs should be considered. What could $60 million dollars do to provide sexual education? How far could $60 million dollars go to covering health insurance/programs to low-income people without access? What other affects could this $60 million have on the health system?

I don't like bringing up questions like this because it is easy for me not to. It is easy for me to jump on the 'eliminate cervical cancer' bandwagon, without thinking about how those limited resources are spent. Considering state Medicaid resources are budget constrained, this money could be draining programs for the Medicaid population as a whole, which is most likely the disabled population.

The avoidance of these discussions, I believe, is a central problem of the American health care system. Line-item decisions are made by the legislature on coverage decisions, such as mandating the HPV vaccine. These decisions are not contextualized within the larger system. Questions above are not asked; alternatives not weighed, because the decision making process is made item by item, rather than contextualized with alternatives being weighed. Instead, decisions are made one-by-one on an up or down basis, largely influenced by special interests groups - both corporate and consumer.

Is this argument too utilitarian? Maybe.

I don't know what the answer is. Oregon's health care rationing program was not successful. But was it a step in the right direction? I don't know. All I am saying, is dialogue to these decisions needs to be open. By not taking about these ethical tradeoffs- we are ignoring the problems and making simple decisions that may make us feel we are doing the right thing-- when that in fact, that may not be the case. Not talking about the trade-offs is an ethical decision in and of itself.

We need to recognize complexity. As a nation, we need to stop being afraid of complexity and difficult, ethically challenged decisions. Only such a recognition and acknowledgment will result in better decisions we make as a public.