Tuesday, July 15, 2008

Prozac for Pets and Health Care Reform

In my section of Harvard Medical School’s required first year course in “Medical Ethics and Professionalism” this spring, we opened several of the seminar sessions going around the room canvassing for ethical issues we had encountered during the week. My aim was to encourage the students to see ethics as something always around us, part of everyday life, not as a bucket of high level issues (stem cells, persistent vegetative state, etc) that most physicians never encounter.

I kicked off the process by telling the group that after writing a blog entry about one of our class discussions I fretted about not having gotten their permission in advance, even though there was nothing personal in the posting. (They told me to chill out – it didn’t bother the Facebook generation.) We had some wonderfully lively discussions about topics like what a student’s obligations to a sleazy real estate agent were with regard to an apartment rental, and whether promoting attendance at a student run meeting by offering appealing food was an unethical bribe or an acceptable incentive.

The article on “Pill-Popping Pets” in Sunday’s New York Times Magazine was illuminating for me, much like the everyday life vignettes in the ethics class. Drugs for pets is a rapidly growing industry. Pfizer’s Animal Health division earned $1 billion last year, with drugs for “behavioral conditions” as a rapidly growing sector. Last year the FDA approved Pfizer’s Slentrol as the first weight loss drug for dogs! And Eli Lilly is marketing Reconcile, a chewable form of Prozac that tastes like beef, for canine separation anxiety!

Most observers of the U.S. health system agree that we have too little primary care and rely too much on pharmaceuticals and other technological interventions. Seeing the same pattern in our pet care system tells us how entrenched the pattern is.

The article quotes Dr. Ian Dunbar, a veterinarian critic of our approach to pet care, as saying “we lead an unhealthy lifestyle [with our pets] and then rely on drugs to correct it…I have never in my life had to resort to using drugs to resolve a behavioral problem.” With regard to obesity, Dunbar’s common sense approach is “just feed the dog less!”

Given our deeply entrenched values about managing health care – for people and for pets – we can’t expect preaching to drive the reform process. The ecological unhealthiness of SUVs has been obvious for years, but it has taken a rise in gas costs to stimulate a change in our car buying habits. Unfortunately for health care reform, the cost of health care doesn’t stare us in the face the way gas costs do when we fill up the tank. Policy gurus have hoped that high deductible health insurance (“skin in the game”) would drive reform, but for many the approach has simply led to anger at insurance companies and employer purchasers of insurance.

I think the likeliest analogue to the gas pump in health care is Medicare. I'll write more about the ethics of getting a grip on costs in future postings.