126.96.36.199 Ethical analysis of preventive medicine
Roman Catholic morality itself does not distinguish between the ethical assessment of treating pre-existing diseases or that of preventing them. Prevention of disease is part of man’s duty to take care of his health. In this sense, it can be seen as a variant of treat [1: Catechism of the Catholic Church. Nr. 2288. 2008.]. The limited providence that man has as a free and reasonable being requires him to take responsibility, to the best of his ability, for the prevention of diseases that he might contract in the future (this fact is elaborated on in paragraph 2.3 of this section). What is essential is that the preventive act in itself is morally justified and that medicines or vaccines used for this purpose have in principle been produced in a morally responsible manner. Since preventive medicine, like therapeutic medicine, aims to protect the life and/or health of the human person as a whole, it can be legitimised – to the extent that it affects bodily integrity – on the basis of the therapeutic principle (see Chapter I.2.2.3).
In addition, preventive medicine involves socio-ethical considerations. Money spent on preventive medicine cannot be spent on other collective expenditures such as those on education, infrastructure or support for the weak in society. Therefore, the cost of preventive treatments requires social and political consideration. The common good (Chapter VII, Introduction) and the principles of sociality and solidarity (see Chapter I.2.2.5) require that prevention programmes should be available to all who can benefit from them, regardless of their financial means.
In countries where healthcare is largely collectively funded, the (financial) burden that preventive health programmes place on society must be taken into account. This requires economic analyses of preventive programmes. Conclusions from such analyses are straightforward and unambiguous if a prevention programme turns out to be cheaper than the costs of treating diseases and conditions and their consequences, including those of the relevant treatments, hospital admissions and admissions to nursing homes. As already explained in Chapter VI.1.1.1, the results of economic analyses fall unfavourably if many people die without the application of prevention measures, while when they are applied, many people survive. When more people survive, it often costs society more than when they die, because, as a consequence, people with multiple pathology often stay alive, whose treatment entails high costs for society. Incidentally, this can also occur when people are cured by treatment of a disease and/or do not die from it, but curing or preserving life through therapeutic intervention is generally more easily perceived as a good thing. One tries to weigh the extra costs that will be incurred by the prevention programme against the survival gain and quality of life (well-being) in this gained life time through the QALY (see Chapter VI.1.1.1). However, the QALY does not appear to be an adequate measure to capture the ratio between the costs of prevention programmes on the one hand and those of survival gain and quality of life during the life years gained from them on the other. The Dutch Raad voor de Volkgezondheid en Zorg (Council for Public Health and Care) [2: Raad voor de Volksgezondheid en Zorg. Zinnige en duurzame zorg. Zoetermeer 2006.], therefore, recommended including the burden of disease of a disease or condition in addition to the QALY: in this opinion, on a scale of 0 to 1, chalk nails would represent a very low burden of disease (0.02), whereas a non-Hodgkin lymphoma would represent a high burden of disease (0.97). When this disease burden thus quantified is taken into account, a QALY might cost €10,000 to €80,000 in the Netherlands. For vaccination, one uses a QALY cost of €20,000. [3: T.G. Kimman, H.J. Boot, G.A. Berbers, P.E. Vermeer-de Bondt, G. Ardine de Wit and H.E. de Melker. Developing a vaccination evaluation model to support evidence-based decision making on national immunization programs. Vaccine. 2006/04/18 ed 2006, 24, 4769-4778 doi:10.1016/j.vaccine.2006.03.022.] [4: Gezondheidsraad. Brief aan staatssecretaris van Volksgezondheid, Welzijn en Sport: Verbindende notitie van Gezondheidsraad en Zorginstituut Nederland bij advies over vaccinatie tegen gordelroos (15-7-2019). Den Haag 2019.]
However many difficulties these analyses may have, they can be helpful in guiding or reducing the price of diagnostic tests or preventive treatments (drugs or vaccines). Producers of laboratory tests, drugs and vaccines often try to make large profits on their new, usually patented products: an economic analysis can provide insight into the costs of producing preventive agents on the one hand, and the costs that might be saved if they prevent a disease, the treatment of which might also entail the necessary costs, on the other. This played a role in negotiating the price of the HPV vaccine. [5: V.M. Coupe, J.A. Bogaards, C.J. Meijer and J. Berkhof. Impact of vaccine protection against multiple HPV types on the cost-effectiveness of cervical screening. Vaccine. 2012/01/14 ed 2012, 30, 1813-1822 doi:10.1016/j.vaccine.2012.01.001.] Altogether, economic analyses can be helpful in a choice for or against a prevention programme: much of the trade-offs will continue to depend on the prudence of the responsible administrators.
In non-Western European societies, including the United States, access to healthcare is not readily available to all. This also applies to prevention programmes. This goes against the demands of the common good and against the principles of sociality and solidarity.