Who Decides?

In April 2014, New York Times journalist, Elizabeth Rosenthal published an article entitled, “Even Small Medical Advances Can Mean Big Jumps In Bills.” As the title suggests, Rosenthal’s article reported advances in diabetes technology as minor, but costly. She refers to persons with diabetes as a “captive audience” responsible for “spawn[ing] lines of high priced gadgets.” (Rosenthal, 2014). Quoting the national expenditure on diabetes at $245 billion in 2012, Rosenthal drives home her point that the innovations to technologies made by diabetes supply companies are little more than planned obsolescence and thus not worth the expense (American Diabetes Association, 2012).

Diabetes advocates and bloggers took to social media to challenge the claims made by Rosenthal (Close, 2014). Advocates accused Rosenthal of misrepresenting a subgroup to which she did not belong and of potentially damaging their likelihood of coverage of future technological advances. One advocate explains, “it’s wrong to paint a broad picture of pumps and CGMs as “wanna-have gadgets” rather than medical necessities. What a terrible message to be broadcasting just at a critical moment when we patients are working so hard to encourage coverage of these necessities!”

Coverage of advances and innovative technologies and treatments for persons with diabetes is threatened beyond the reach of the media. Perhaps a larger contributor to and influence over cost-benefit analysis performed by insurance companies, are the guidelines set forth by biomedical ethicists. In the dangerous line of declaring right and wrong, bioethicists’ works are subject to misinterpretation. Consider the following discussion of ordinary verses extraordinary treatment.

Beauchamp and Childress, authors of the widely-circulated bioethics text, Biomedical Ethics, set for distinctions between what is to be considered an ordinary or extraordinary treatment. Ordinary treatments, or those which cannot be omitted or declined are likened to “obligatory”, “customary”, “usual”, “simple”, “natural”, “noninvasive”, “inexpensive”, or “routine” treatment. In contrast, extraordinary treatments, or those which may be legitimately omitted or declined are likened to “non-obligatory”, “unusual”, “uncustomary”, “complex”, “artificial”, “invasive”, “expensive”, or “heroic” treatment (Beauchamp & Childress, 2012). While Beauchamp and Childress do draw attention to the danger in such a broad categorization, calling it “morally misleading” and too subjective, they fail to address a most vital question. Who decides?

In the cost-risk-benefit analysis behind every decision about a course of medical treatment, whose expertise is most valued? Who gets the final say? The doctor? The patient? The insurance company? The answer is not the patient, for if it was, every patient would have the medical devices they see fitting for their lifestyle. Nor do the doctors get the final say, for if they did, every patient would have the medical devices recommended to them by their doctors. By process of elimination, then, the answer of who decides whom gets a certain treatment, is the insurance company. By looking to the ethical guidelines on distinctions between ordinary (inexpensive) or extraordinary (expensive), the insurance companies can justifiably (legally) deny a person with diabetes access to an innovate management device. The same continuous glucose monitor a diabetes caregiver and advocate credits for saving her daughter’s life is deemed ‘unnecessary’, “complex”, and ‘expensive’ by her insurers. In the dangerous line of declaring right and wrong, bioethical guidelines, by proxy, threaten access to advancing technologies for people with disability.

American Diabetes Association. (2012) Economic Costs of Diabetes in the U.S. in 2012. Retrieved October 26, 2015.

Close, K. (2014, April 9). An Open Letter to The New York Times: Treating Modern-Day Diabetes with Modern-Day Therapies and Technologies. Retrieved October 26, 2015.

Rosenthal, E. (2014, April 5). Even Small Medical Advances Can Mean Big Jumps in Bills. Retrieved October 24, 2015, from http://www.nytimes.com/2014/04/06/health/even-small- medical-advances-can-mean-big-jumps-in-bills.html?_r=4