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                        13 / 02 / 17

                        ​The case against choice in healthcare

                        • In recent months, bariatric surgery has been touted as a potential cure for type 2 diabetes. Whether or not it’s the miracle cure being claimed remains unclear, but the debate about its use illustrates how flawed ethical assumptions and cultural guesswork shape our healthcare.

                          The breakthrough

                          Type 2 diabetes is an unforgiving condition. Over time, medications can become inefficient at preventing its progression and sufferers may experience blindness, loss of limbs and even death. It is increasingly being called a global health pandemic – in 2006, the United Nations even adopted a resolution to combat diabetes.

                          The costs of treating the disease are enormous. There are over 3.5 million people in the UK with type 2 diabetes, and over 368 million adults worldwide, with an estimated 7 million new diagnoses each year. By 2030, an estimated 490 billion USD will be spent annually on the disease. In the UK, the National Health Service (NHS) currently spends as much as £1.5 million per hour on diabetes.

                          Bariatric surgery, on the other hand, costs as little as £6,000 per patient, which pales in comparison to the cumulative costs that incur during a lifetime of diabetes care. The surgery is effectively a stomach bypass, an invasive procedure generally used to combat severe obesity, but one found to almost immediately lower the blood sugar levels of sufferers of type 2 diabetes.

                          However, only people with a BMI over 30 are eligible for the treatment in the NHS. And only a fraction of those entitled to the surgery are put forward for it. So why is this relatively inexpensive surgery restricted when it could potentially help in the fight against one of the world’s fastest growing and most expensive health pandemics?

                        • Philosopher and ethnographer Annemarie Mol

                        • A matter of choice

                          The debate around bariatric surgery reveals conflicting beliefs about the different responsibilities of patients, medical professionals and the government in managing people’s health. The choice to undergo bariatric surgery could in part be being restricted by a healthcare system that believes we can instead choose alternative lifestyles that would render it unnecessary.

                          Philosopher and ethnographer Annemarie Mol has argued that medical healthcare systems are increasingly motivated by what she calls “the logic of choice”. This assumes that giving patients choice over their healthcare is the best practice. Whereas in the past health was seen as something beyond our control – either the outcome of fate or the actions of a paternalistic doctor – increasingly we are being encouraged to take an active role in our own health. We are no longer referred to as “patients” in the NHS, but “clients”, “service users” or “consumers”.

                          There are of course advantages to encouraging choice in healthcare. It may inspire us to be active in safeguarding our health. However, Mol argues that there are significant disadvantages to applying “the logic of choice” to health.

                          Our emotions, social networks, finances and beliefs all shape our health behaviours day to day. Our choices are never culturally neutral or coldly rational. Those asking people to make decisions about their health need to take into consideration the cultural component of decision-making.

                          Furthermore, people are being asked to make choices about their own healthcare with limited information and medical knowledge. UK doctors are the first to admit that they don’t have time to explain to their patients what they’re choosing for themselves. Asking people to make choices about their healthcare might seem ethical, but a glance beneath the surface shows that it is fraught with such problems.

                          Mol argues that instead finding ways to enable people to receive the procedures and medications that will benefit them most should be the guiding priority. This involves in-depth consultations with a doctor before decisions are made.

                          A conflict of ethics

                          In the UK, teams of psychologists, academic GPs and behavioural insights researchers have been enlisted to find ways to reduce the number of people developing type 2 diabetes. These initiatives target people’s health choices day to day, and are part of a wider shift in government spending towards preventative healthcare. Recent public behavioural campaigns – such as the DoH M&C Saatchi ‘Change4Life’ campaign – attempt to motivate people to make the right health decisions well before they get sick.

                          By directing funds towards preventing illnesses, the public are being encouraged to believe we have choices. In practice, however, our choices are limited by internal decisions about NHS spending. Cultural factors also mean that the extent to which we have choice over our healthcare is debateable.

                          The people behind the headlines

                          From 2008-2011 I worked in an academic team studying public health interventions that attempt to empower people to make better health decisions. Often people confided in me that while they knew instinctively that they needed to change their health behaviours – to eat less and exercise more – the circumstances of their lives made it really hard to make the ‘right’ decisions.

                          People with young children, sick parents and a full time job often just grabbed what they could to eat before jumping in the car and getting on with their busy days. Many had limited financial support to make changes in their lives – paying for a gym membership, for instance, or buying healthier food. Moreover, people I interviewed had a very limited understanding of what diabetes was and how it could affect them personally.

                          If a person like this develops diabetes, the chances of them controlling it on their own are low. They’re simply not well placed to make the choices that are best for their health. Therefore, it would be wrong to deny them access to a surgery if it could improve the quality of their lives as diabetics.

                          Do no harm

                          The debate over bariatric surgery is an excellent example of why prioritising good patient care should come before the belief that choice alone is ethical. While espousing choice, our healthcare system both limits it through policies such as the BMI restriction on bariatric surgery and overestimates its efficacy by ignoring the socio-economic and cultural factors that impact people’s decision making. Agencies like Flamingo are therefore in the perfect position to gather vital information on people’s everyday lives and the cultural dynamics of health that can improve healthcare outcomes.

                          Health through the Culture Lens is a weekly series exploring important cultural currents in health and pharma

                          About the author

                          Having recently finished an internship at Flamingo, Sonia Smith is completing an ESRC funded PhD in the department of Anthropology at University College London. She has an MSc in Medical Anthropology and has worked as an ethnographic researcher at the University of Cambridge in the Department of Public Health and Primary Care. She is a co-author of the UCL-Lancet Commission, ‘Culture and Health’ (2014) and has worked as a consultant researcher for Novo Nordisk’s partnership programme, Cities Changing Diabetes.

                          Image source: NBC via the Chicago Tribune

                          • Article by Sonia Smith