Medicine: “A Moral Hazard”

A new study and a commentary in JAMA Internal Medicine propose that effective medicines can be a “moral hazard.” Takehiro Sugiyama and colleagues analyzed data from the National Health Health and Nutrition Examination Survey (NHANES) and found an association between using cholesterol-lowering statin drugs and the consumption of fat and calories. They found that people taking these drugs were more likely to increase the calories and fat they ate over time. They also note a faster rise in BMI for people receiving statins.

Commenting on these findings, the authors of the study take on a distinctly moralizing tone:

We believe that the goal of statin treatment, as with any pharmacotherapy, should be to allow patients to decrease risks that cannot be decreased without medication, not to empower them to put butter on their steaks.

Seriously. That was their bottom line.

In case you missed their point, Editor Rita Redberg provided her own emphatic commentary:

This article raises concerns of a potential moral hazard of statin use, in addition to the already known adverse effects.

The Boston Globe got their point and proclaimed: “Statins May Lead Some Patients to Pig Out” in a bold headline.

Perhaps it’s not surprising that these moralistic themes are built upon a shaky observational foundation. Redberg and Sugiyama are suggesting a reconsideration of evidence-based treatment for high cholesterol based on self-reported data well-known to be unreliable. “Self-report–based estimates of energy intake offer an inadequate basis for scientific conclusions.” That title for an article by Dale Schoeller and a collection of some of the top experts in nutrition research provides a clue that these folks are on thin ice.

Further, even if the dietary intake data were rock solid, all they would have found is an association, not causality. A real experiment is necessary for causality.

It’s noteworthy that the authors barely mention obesity in their commentary. The concept of treating obesity is completely absent. But untreated obesity is a key factor for high cholesterol.

Equally distressing as the sloppy science is the unsound moralistic behavioral theory. The notion of moral hazard is a seventeenth-century concept used to suggest fraud or immoral behavior on the part of an insured party.

This notion of moral hazard, when applied to health insurance, has been used justify limiting health coverage for people who need it. People who are sick don’t care about their health if someone else is paying the bill. Or so this thinking goes. It fuels the promotion of high-deductible plans with meager benefits.

Conjuring up moral hazard as a reason for withholding evidence-based medicine is new to us. It seems contrary to the fundamental purpose of physicians, to heal — not condemn — the sick.

“Morality is simply the attitude we adopt towards people whom we personally dislike.” — Oscar Wilde

Click here to read more in the Boston Globe, here to read the study in JAMA Internal Medicine, and here to read the Redberg commentary. Click here and here to read more about moral hazard.

Deadly Sins in York Minster, photograph © Gareth Williams / flickr

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