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May 27, 2005

What is a disease?

The recent furor over Viagra for sex offenders also generated heated debates over whether Medicaid should cover Viagra for anyone. Pro- and con-arguments seemed to be trading on core assumptions about the nature of disease and the goals of medicine. So, I thought it might be fun to examine some of these conceptual questions in greater detail.

The debate about public insurance coverage for Viagra unfolds in the following context: Healthcare resources are finite. We can't afford to cover every effective treatment for everyone. So, how do we decide which treatments should be covered by public insurance?

A good rule of thumb is that medical insurance should cover the prevention and treatment of disease, but not recreational or cosmetic procedures. This model treats health insurance like a car warrantee. If something breaks, they'll fix it. If your warrantee includes a service plan, you can also take the car in for tune-ups, oil changes, and other preventative car care. But if you want to pimp your ride, you'll have to buy your own neon lighting kits and rear windshield decals because your warrantee doesn't extend to the car equivalent of cosmetic surgery.

This model works well for cars because there's an objective standard for car "health," not to mention a strict expiry on the warrantee. The car is considered healthy if it performs to factory specifications. The warrantee will pay to bring your car back to health.

The problem with treating health insurance like an extended body warrantee is that there's no comparable standard of health for human beings. There are easy cases like broken bones and malignant tumors, but in many cases, the model offers no clear guidance. There's too much variability within the normal population. We recognize this in terms of height and weight. There's always going to be a range of weights and heights in a population. Being above or below average doesn't necessarily mean there's anything wrong with you--except at the very extreme ends of the distribution, and even then it's not necessarily clear cut. But we're often prepared to cover treatments for people at the very extreme ends of the distribution, even if we can't identify any specific pathology. For example, most people would support publicly-funded medical treatment for a child who would otherwise become a midget or giant. They wouldn't ask whether the child was suffering from a documented growth hormone secretion defect, or whether he was just "naturally" destined to be 3 feet tall.

The case of Viagra is complicated because there's a range of erectile function among normal, healthy men. Maybe the distribution looks like a bell curve with the porno woodsmen and the asexuals anchoring the tails of the distribution, everyone else somewhere in the middle.

Most people would consider total impotence in a very young man to be a serious medical problem. Any reasonable "body warrantee" would cover treatment for such a grave and unusual condition. We also assume that it's "normal" for erectile function to decline with age. There's no doubt that it's the statistical norm, but just because it happens to most people doesn't mean that it isn't a medical condition worthy of treatment. Cataracts are a normal part of the aging process--but we're not prepared to let the indigent elderly go blind because it's "normal" for the lens of the eye to develop faults with heavy use.

We used to assume that dementia was just a normal part of aging. Luckily, we now see age-related cognitive decline as a medical condition, not an inevitable part of the aging process. When an older person becomes confused, we don't just chalk it up to some nebulous "aging process", we actively seek out the pathology and try to correct it. Maybe a similar paradigm shift is overdue for age-related declines in erectile function.

If the goal of medicine is to fix what's broken, we need some standard for normality. Perhaps the correct standard is based the typical level of function in a population. In that case, it's the extreme outliers who deserve medical treatment. In that case, the question becomes population we should use for comparison. If we compare an older guy to the population at large, he might be an outlier, but not if we compare him to other people his age.

We also have to ask whether the norms for a given population are healthy or desirable. It begs the question to say that whatever is typical is healthy. Consider the heights and weights of North Korean children. In this population, a typical weight is not a healthy weight because malnutrition is so pervasive in North Korea. Likewise, it might turn out that the average IQ of the older population is lower than it should be because of treatable dementia. What looks like normal aging might actually be widespread pathology.

We could refine our definition of "disease" in various ways. One strategy is to define health in terms of functionality and construe disease as deviation from functional health. On this view, osteo-arthritis treatments should be covered even if wear and tear on the joints is paradigmatically normal for old people. It's quite reasonable to say that the joints are designed to flex painlessly and therefore that stiff or painful joints deserve medical attention.

The functional model isn't a free pass to objectivity or rigor, however. Functional idealizations are useful, but they don't eliminate the need for further controversial value judgements. These days, children who can't sit still in school are often diagnosed with attention deficit disorder (ADD). ADD-skeptics sometimes argue that the problem lies with a system that requires rambunctious kids to sit down and shut up for long periods. In other societies, energetic kids might have had more outlets in physical work and rough play. Be that as it may, in our society, the capacity to sit still and listen is very important to one's future prospects. If you want to use a functional criterion for insurance coverage, you have to ask whether to include this ability in your model. Personally, I think that if person is constitutionally incapable of paying enough attention to get by, even when they want to, then they've got something sufficiently disease-like to warrant insurance coverage.

Despite it merits, the functional model doesn't shed much light on the Viagra coverage controversy because it's not clear which function(s) the treatment is supposed to address. The most obvious biological function is reproduction--yet nobody's pretending that Viagra is primarily a fertility treatment. At this point someone will drag in evolutionary biology, but discovering which functions promoted fitness in a hunting and gathering society doesn't say much about what our medical priorities should be today.

Of course, we all know that the real function at stake is recreational sex. By itself, the functional model can't tell us how much priority we should assign to preserving the capacity for sexual pleasure vs. other biological functions. I'm inclined to assign that particular function a relatively high priority, but the functional model doesn't advance my case.

Debates about the true nature of disease seem to proceed in a circle. We want to find some objective standard for pathology. Someone proposes a plausible criterion. Skeptics ask why we should care about that standard, and we're back to where we started.

I think it's a mistake to base health care allocation on a concept as ill-defined as "disease." The fundamental problem is that we're looking for a bright line that doesn't exist. We started with a pre-scientific concept and we're making heroic efforts to reconcile it with modern science and medicine as it's practiced in our culture. The fit isn't always perfect, nor should we expect it to be.

The decision about whether to cover Viagra shouldn't depend whether erectile dysfunction meets someone's definition of disease. What matters most is plain old cost-benefit analysis. Obviously, not every beneficial intervention is health care. However, separating medical treatment from non-medical treatment is not a serious practical problem. As long as we're talking about prescription drugs or procedures that can only be administered by physicians, we're talking about potential candidates for health insurance. (There are legitimate background questions about how medicine and medical power are delineated in our culture. We can argue about whether a drug ought to be available over the counter, or whether non-physicians should be allowed to deliver a certain type of care, but these issues are peripheral to this discussion.)

So, what of Viagra? Ultimately we're talking about a relatively expensive drug that provides symptomatic relief for a non-lethal condition. Advancing sexual health is a worthy goal, but if that's our objective, we'd do better to allocate more of our budget to preventing and treating high blood pressure and diabetes, which are among the leading causes of both impotence and premature death. I also support Viagra coverage for very severe cases of erectile dysfunction with a clear organic cause, such as prostate surgery, or advanced diabetes.

It's clear that intense promotion and high demand have resulted in more insurance coverage for Viagra than the drug deserves. It's equally clear that there are good reasons to cover some or all of the cost of the drug under certain circumstances. These decisions have little or nothing to do with whether erectile dysfunction is a "real disease."

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Comments

As a woman whose husband is in his fifties and takes Viagra 70% of the time, I'd say ED, rather than being a disease, is the equivilant of grey hair, wrinkles, the wearing and tearing down of joints. Something you don't want, but it's there anyway. That's really all that it is. Sad but true. Aging is sad but true. One of those nasty tricks life plays on you.

That said, the question could be...is aging a disease.

Upon an initial reading, one thought is in regard with indirect economic stimulation. A healthy sexually active man or even more so a refound sexually active man one would assume would be economically advantageous. An individual with a higher self-image/self-esteem would, one would think, would have increased productivity at work, possibly be more socially active and therefore more economically active consumer. Disregarding the procreation issues economically. I realize this skirts the issue of the medical issues and concerns, but the U.S. health industry isn't really concerned about health as much as industry anyway, is it?

It's hard to write about this without continual puns revealing themselves in the writing.....

Absolutely awesome post...On first glance I don't see any holes...it was a good treatment of some available frames and the biases and blindspots those frames have and might hide. Posts like this are why I way-<3 this blog so much. It's my favorite blog that isn't about obscenity laws and conservative comic strips.

The stories on this made it sound as though medicaid had some kind of sex offender viagra distribution program. Its typical sensationalism from the media. People die every day in America because we don't have universal health care coverage and it never makes the news. Only this crap does.

What about gents who get their prostates yanked and lose the function? Is that a two-fer: cancer plus no sex?

The thing with recreational sex drugs is that technically, contraception is also a drug to enable people to have "recreational" sex, and I think insurance should definitely cover contraception. Of course, your model of cost-benefit analysis makes covering contraception a necessity--years and years of pill use will never add up to the cost of just one pregnancy and childbirth.

The term "recreational sex" bugs me, though. I mean, yeah, you do it for fun but also because it's a basic body function. Most importantly, most sex occurs in the context of monogamous relationships that are the primary relationships in the lives of the people involved, and those relationships can be damaged very badly if the sex dries up. When Viagra first came out, before it became a legendary pseudo-aphrodiasiac, the initial wave of men who took it reported improved marriages. It wasn't just about getting their rocks off; it was the connection with their wives that they wanted to get back. If you are married, the strength of that relationship is critical to your mental health, so when weighing the benefits of Viagra, I think we have to take mental health and marital stability into consideration.

I think you can make the same argument for cosmetic surgery as you make for erectile disfunction medication. Both help men and women enjoy their life more. Both can, but not necessarily will lead men to more sexual success. My opinion is that any government paid medical coverage should be limited to more basic things like eyesight, hearing, cognitive ability, and lack of pain, plus, of course, disease prevention and cure.

Vaughn: would you make an exception for cosmetic surgery for victims of accidents?

And just to throw another potentially tough ones into the "what should we cover" fray: What about treatments for, say, psoriasis? What about adult full-body acne?

"here's no doubt that it's the statistical norm, but just because it happens to most people doesn't mean that it isn't a medical condition worthy of treatment."

Double-negative. You lose points for that.

But Lawrence, she used "beg the question" correctly! My heart went pitter-pat when I read that sentence!

Also, Lawrence, you should know that although it is never acceptable to use a double negative to signify a negative, it is acceptable to use one to signify a positive or potential positive if context and emphasis are sufficient. In fact, I think that it's possible that the plebeian misapplication of the rule is, in fact, the practice of being overinclusive in its prohibitions! It is you who fails the gods of anal copy editing!

Actually, Eli, "it is you who FAIL the false gods etc." No "s" on fail. I forgive the doubling of "in fact" as just poor proof-reading.

Are we having fun yet?

although it is never acceptable to use a double negative to signify a negative

Yours is a not incontrovertible hypothesis.

Amanda, I agree that "recreational sex" makes sexual health sound less important than it really is.

Insurance should cover reconstructive surgery for people who are seriously disfigured. (A perfectly enlightened society wouldn't give a rat's ass about whether a person's face is symmetrical, but no such society exists. In the meantime, it's important to give people with those problems the chance at a decent life.) I'm always touched by the stories about the doctors and nurses who go to developing countries to fix cleft lips and other deformities. That's legitimate medical treatment.

It's telling that we never see kids like that on our streets, no matter how poor they are. Our society just isn't prepared to allow cleft lips to go untreated, no matter what their economic status. It's not just frivolousness or queasiness on the part of our culture (although there's some of that involved). I think we really recognize that it's barbaric to allow these kinds o obvious malformations to go untreated when we can fix them quickly and easily. I just wish our society was as sensitive to less visible, but equally debilitating conditions.

Just to be clear -- Eli's right, and Lawrence is wrong, at least so long as we're talking Elite White English. Obviously, negative-indicating double negatives are totally standard in many other English dialects, and even us honkeys usually don't have no trouble understanding what is meant.

Also, sweet Jeebus Lawrence, but if "doesn't mean that it isn't" isn't by-the-book White Elite English, (what with its postivie-indicating double negative and all), I'll eat Tucker Carlson's tie.

How did Eli's name get on the post I made, and how did my name get put on a post about yanked prostates? Something is wrong here.

I like that Elite White English can be made into a teutonic acronym. Ewe immer!

Marbury: Zing. Ya got me.

I think your discussion is good as far as it goes, but I think you're being a bit too coy about applying a bit of ol' fashioned cost-benefit analysis.

Somewhat following up on Amanda, I don't really accept the premise that there's a bright line between "necessity" and "recreation," with the state limiting itself to necessities. Take public parks, for instance. The human body functions just fine without a place to play ultimate frisbee. Yup, the heart keeps beating, sugars still get broken into Acetyl CoA, etc. Still, we think that 1) public sector provision of parks is more efficient than private sector provision (mainly because if everyone had their own park, say trying to use their backyard as a park, they'd only use it maybe 5% of every week, and it wouldn't be big enough for many enjoyable purposes.) 2) parks are nice.

So I think that your discussion of ordinary good health vs. enhancement is good, but you miss a whole different way of looking at this: that of utilitarian cost-benefit analysis. If Viagra (or some sildenafil knockoff)cost $0.25 a pop (but, for some reason, it isn't available in the private sector), and it saves some guys' marriage, gives him and his wife pleasure, spares his kids a lot of angst at seeing strife among their parents, etc, then the case for "get him some viagra!" seems pretty compelling even if his declining erectile function is fairly normal. If Viagra cost $500,000 per pill, and the patient is an asexual, then even if he has a bona fide medical problem, perhaps involving unusually hard penile arteries, and he's 22 and never had an erection, I don't think you'd find many who think it's really worth it to get him to have one.

Now, a medical system that micromanaged coverage based on circumstance like that would be unworkable, I realize, but surely it's folly to talk about whether a given treatment should be provided without talking about its costs.

There's much that I agree with in Lindsay's remarks, but I don't think she has provided much support for her claims that "separating medical treatment from non-medical treatment is not a serious practical problem," and hence that decisions about whether, or in what circumstances, health insurance _should_ cover the cost of drugs for ED has "little or nothing to do with whether erectile dysfunction is a 'real disease.'"

What, after all, is the purpose of health insurance? As a purely _practical_ matter, since insurers contract to provide coverage for the treatment of health problems, it is certainly in their interest to delimit the scope of their contractual obligations to those pertaining to health. And for those who finance the whole enterprise through the payment of premiums (or taxes), it is equally important to know what services are being contracted. Since virtually all health insurance contracts appeal to the notion of "medical indications" to (in part) effect the needed delimitation of obligations, and since that notion seems to require appeal to concepts of health and disease/pathology for its explication, it would appear that whether or not some condition qualifies as a "real disease" is an eminently practical concern.

Even if a person would be inclined to let this whole Viagra-to-sex-offenders thing go, it seems to me that an opportunity to take the populist high ground on something like this while making Republicans choose between sex offenders and their sugar daddies in the pharma industry would be too much fun to pass up.

What about the millions of women who've never experienced orgasm? Could that be a disease?

You know there was a FEMALE VIAGRA, but they took it off the market. It was called a QUALUDE.

Come on, Viagra to sex offenders? That's just stupid. Some things are just stupid. That's one of them.

Um.... pallosophy.

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