Your money or your life: a new variation on the Heinz Dilemma - Ethical Aspects

Physician Executive, Jan-Feb, 2004 by Richard E. Thompson

Millions of Medicare-age Americans are drug dependent, not because of addiction but because of common chronic health problems such as diabetes, heart failure, high blood pressure and arthritis. Seniors are up in arms because drug company control of distribution and pricing of pharmaceuticals is eating away hard-earned nest eggs. Who cares? Where's the justice?

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Mrs. Heinz, a 66-year-old widow, suffers from a life threatening chronic illness. She is kept alive by two daily doses of a miracle drug. The drug was discovered by and is produced and distributed by a local pharmacist who charges $2,000 per dose, 10 times the cost of producing the drug.

Mrs. Heinz can no longer afford the drug. She first spent a hard-earned and carefully planned nest egg that, without the illness, would have provided for comfortable living the rest of her life. A public fund-raising effort was successful but could not be sustained over time. Mrs. Heinz has three sons who send her money regularly, but the sons must safeguard their own economic position and consider obligations to their children as well as to their mother, so they cannot totally cover the cost of the drug.

Mrs. Heinz goes deep into debt by taking out a loan, but the borrowed money is soon exhausted and now she can't afford two things, the cost of the drug and loan payments. She maxes out her credit cards, but cannot meet those payments either so the credit cards are no longer honored.

So Mrs. Heinz appeals directly to the inventor/pharmacist. She presents a note from her doctor confirming that she will die without daily doses of this medicine. She asks the pharmacist to supply the drug to her at a cost she can afford. The pharmacist refuses. "Like any other business," he argues, "I am entitled to make a profit."

Normally a law-abiding citizen, Mrs. Heinz is now considering the only option left to her as she sees it, which is breaking into the pharmacist's warehouse and stealing a huge supply of the drug.

Fantasy and reality

That fantasy is a paraphrased version of the Heinz Dilemma, a popular case study discussed in college ethics and psychology classes since 1973. (1,2)

Today, some key features of the Heinz Dilemma are disturbingly familiar. The question of whether or not prescription drug benefits should be included in socialized medicine systems such as Medicare is a hot topic but only in the United States. Angry seniors struggling with a combination of chronic medical conditions, fixed incomes, and unaffordable prescriptions are ordering affordable drugs from Canada. (3,4)

At the present time, this is an act of civil disobedience because it openly flaunts laws against importation of drugs by individuals.

Setting aside for a moment the strong emotions aroused by this issue, what generally accepted ethical principles thread through this complex political, social and economic dilemma?

The answer depends on your choice of ethical perspective. This issue can be viewed as a question of caring, a matter of conflicting rights, a test of virtues and moral character, or an exercise in distributive justice.

* Caring is a feeling that includes elements of spiritual love, protectiveness, and personal involvement. Caring in the extreme is altruism, which means actions are based more on expected results for others than on considerations of one's own welfare. Some consider caring a desirable character trait; some consider it a weakness. Caring is a major feature of the professional ethic, so it is expected of doctors and nurses. But those running a business cannot be expected to become personally involved with each customer.

So when people ask, "Don't drug companies care?" the answer is, "No," but that answer does not justify a conclusion of immoral behavior by the drug companies.

* A right is something justifiably claimed by an individual. The claim might be based on tradition and experience (a customary right), law and government (legal rights and civil rights), or simply existence as a human being (human rights). There is no such thing in a civilized society as an absolute right. Rather, rights conflict. Whether a right exists or not is an ethical discussion. Which person's or groups rights prevail is a legal battle or a political battle and some of these battles are long, bitter and famous. Which is greater, the fetus' right to become a human, or a person's right to choose life without raising a baby? Which is greater, the smoker's right to light up or the non-smoker's right not to inhale second-hand smoke?

So far, no one denies a sick person's human right to medication or a drug manufacturer's customary right to make a profit. The drug companies are winning the political battle over which right prevails.

* Virtue ethics is the traditional view of ethics as moral philosophy. Morality is concerned with judging human actions either good (angelic) or bad (evil). Virtues exhibited by people whom moralists judge good include the four basic virtues proposed by Aristotle: