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Medicine is meant to eradicate disease, not cause more of it.
Moral Hazard vs Morality Approaches in the Opioid Crisis Tafari Mbadiwe, MD, JD
Medicine is meant to eradicate disease, not cause
more of it. So earlier this year, when economists
Jennifer L. Doleac and Anita Mukherjee published a
paper suggesting that widening naloxone access in
urban communities might actually increase opioid
abuse, physicians across the United States found
themselves in the unfamiliar position of having to
defend the use of a lifesaving medication.
No punches were pulled. Until now, I had not
realized that economists and public policy experts
were in the habit of advocating, if obliquely, for de
facto death sentences for opioid-related crimes, wrote Jeremy Faust, MD, a prominent emergency
physician, in a widely circulated takedown of the study published in Slate. The study authors, meanwhile,
insisted that they were merely dispassionate purveyors of statistical truths. Clear battle lines were
drawn: economists on 1 side, physicians on the other. Either the numbers dont lie, or they tell nothing but
lies.
For all the consternation it caused, the argument presented by Ms Doleac and Ms Mukherjee is actually
fairly straightforward: because naloxone prevents overdoses, it also nudges users toward riskier
behaviors, which has the overall effect of increasing opioid use. Naloxone acts as a sort of safety net for
opioid users: if they go too far, naloxone will be there to catch them. But because users (and, potentially,
would-be users) are aware of the safety net, they respond by taking more heroin or fentanyl or
OxyContin than they otherwise would. Naloxone insures users against the risk for overdose, so they take
more risks.
Economists refer to the idea that insurance can encourage risk-taking as moral hazard. The notion that
moral hazard might affect medical decision making was first broached in 1968 by economist Mark Pauly
in an essay arguing that comprehensive, zero out-of-pocket-cost health insurance would lead to
inefficient consumption of healthcare resources. Mr Paulys piece has been thoroughly criticized, and
not just because it seems to assume that wed all happily check ourselves into the hospital indefinitely, if
only we could afford it. Still, its probably the single most influential article in healthcare economics, and
its conclusions are the intellectual scaffolding for the labyrinth of copays and deductibles that American
physicians and patients know all too well.
Intentionally or not, Mr Paulys characterization of healthcare consumption as a moral hazard problem
stands in opposition to the concept of preventative medicine. Mr Pauly says as much: his analysis
explicitly excludes preventative medicine from consideration. In Mr Paulys estimation, healthcare with
no out-of-pocket costs would cause people to go to their physician when they didnt strictly need to,
which he viewed as an inefficient and wasteful allocation of capital. Thats why his paper stumps for
copays and deductibles: raising the point-of-sale costs of going to the physician might make people think
twice before they waste precious resources on a nonailment.
Advocates of preventative medicine actually agree with Mr Pauly up to a point. Both sides recognize that
lower up-front costs promote nonemergent healthcare usage, but see that extra consumption as an
opportunity to identify minor problems before they become major ones. They believe that an ounce of
prevention is worth a pound of cure. Its tough to reconcile the 2 views; you more or less have to pick 1
side or the other.
Exactly what the optimal approach to the opioid crisis looks like has a lot to do with whether its a moral
hazard problem or a preventative medicine problem. Moral hazards call for deterrence, and in those
circumstances, risk mitigation efforts such as increasing naloxone availability only exacerbate the issue
by pushing users toward riskier and risker behavior, meaning that its better to disrupt the supply chain in
the hopes that the drugs never make it to the street in the first place. Connecticut, for example, has
drastically increased its prosecution of low-level opioid retailers, with the intention of making it more
difficult for users to obtain drugs. That makes sense, as long as the opioid epidemic is mostly a moral
hazard problem and if were comfortable regarding narcotic addicts as criminals. In contrast, states such
as Maryland and North Carolina have broadened the availability of naloxone, which is what you should do
if opioids are a preventative medicine problem and its users are patients who should be treated by
physicians. So which is it?
Actually, its both. The study by Ms Doleac and Ms Mukherjee ultimately found that a regions response to
expanded naloxone availability depended largely on the presence of opioid treatment facilities in the
area. In cities with many of those facilities, making naloxone more accessible decreased opioid use and
related crime; in areas with fewer centers, the opposite happened. Its not hard to see why: If there are no
treatment facilities around, an emergency naloxone shot saves a life but also reiterates the availability of
an overdose safety net, and maybe even quietly suggests taking a bigger dose the next time around.
Moral hazard abounds. But if there are treatment beds available, a lifesaving dose of naloxone might well
lead to in-patient rehabilitation, which, in turn, could help break the cycle of addiction before the worst
happens, just as the preventative medicine advocates drew it up. It turns out that the availability of
addiction treatment facilities forms the dividing line between moral hazard and preventative medicine
problems.
And thats where Ms Doleac and Ms Mukherjee and their critics in the medical community see eye to eye.
Dr Faust, the emergency department physician, points out that the treatment goal is to provide [opioid
users] with both short- and long-term treatment options, which certainly means opening more
treatment centers. Meanwhile, the study hes ostensibly criticizing concludes that [i]ncreasing access to
drug treatment, then, might be a necessary complement to naloxone access in curbing the opioid
overdose epidemic. Either way, treatment infrastructure is the key to transforming opioid use into the
kind of problem that physicians, not lawyers and judges, can solve. Opioid users are patients, not
criminals, and doctor knows best.
References
1. Doleac JL, Mukherjee A. The moral hazard of lifesaving innovations: naloxone access, opioid abuse,
and crime [published online September 30, 2018]. SSRN. doi: 10.2139/ssrn.3135264
2. Faust JS. Are we reviving too many opioid overdoses? Is this really a question? Slate.
https://slate.com/technology/2018/03/a-new-paper-suggesting-narcan-might-have-downsides-is-
presenting-an-immoral-case.html. March 8, 2018. Accessed November 6, 2018.
3. Pauly MV. The economics of moral hazard: comment. American Econ Rev. 1968;58(3):531-537.
4. Gladwell M. The moral-hazard myth. The New Yorker.
https://www.newyorker.com/magazine/2005/08/29/the-moral-hazard-myth. August 29, 2005.
Accessed November 6, 2018.
5. Rothberg RL, Stith K. The opioid crisis and federal criminal prosecution. J Law Med Ethics.
2018;46(2):292-313.
TOPICS: MEDICAL ETHICS MEDICINE
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Home » More » Ethics
Medicine is meant to eradicate disease, not cause more of it.
Moral Hazard vs Morality Approaches in the Opioid Crisis Tafari Mbadiwe, MD, JD
Medicine is meant to eradicate disease, not cause
more of it. So earlier this year, when economists
Jennifer L. Doleac and Anita Mukherjee published a
paper suggesting that widening naloxone access in
urban communities might actually increase opioid
abuse, physicians across the United States found
themselves in the unfamiliar position of having to
defend the use of a lifesaving medication.
No punches were pulled. Until now, I had not
realized that economists and public policy experts
were in the habit of advocating, if obliquely, for de
facto death sentences for opioid-related crimes, wrote Jeremy Faust, MD, a prominent emergency
physician, in a widely circulated takedown of the study published in Slate. The study authors, meanwhile,
insisted that they were merely dispassionate purveyors of statistical truths. Clear battle lines were
drawn: economists on 1 side, physicians on the other. Either the numbers dont lie, or they tell nothing but
lies.
For all the consternation it caused, the argument presented by Ms Doleac and Ms Mukherjee is actually
fairly straightforward: because naloxone prevents overdoses, it also nudges users toward riskier
behaviors, which has the overall effect of increasing opioid use. Naloxone acts as a sort of safety net for
opioid users: if they go too far, naloxone will be there to catch them. But because users (and, potentially,
would-be users) are aware of the safety net, they respond by taking more heroin or fentanyl or
OxyContin than they otherwise would. Naloxone insures users against the risk for overdose, so they take
more risks.
Economists refer to the idea that insurance can encourage risk-taking as moral hazard. The notion that
moral hazard might affect medical decision making was first broached in 1968 by economist Mark Pauly
in an essay arguing that comprehensive, zero out-of-pocket-cost health insurance would lead to
inefficient consumption of healthcare resources. Mr Paulys piece has been thoroughly criticized, and
not just because it seems to assume that wed all happily check ourselves into the hospital indefinitely, if
only we could afford it. Still, its probably the single most influential article in healthcare economics, and
its conclusions are the intellectual scaffolding for the labyrinth of copays and deductibles that American
physicians and patients know all too well.
Intentionally or not, Mr Paulys characterization of healthcare consumption as a moral hazard problem
stands in opposition to the concept of preventative medicine. Mr Pauly says as much: his analysis
explicitly excludes preventative medicine from consideration. In Mr Paulys estimation, healthcare with
no out-of-pocket costs would cause people to go to their physician when they didnt strictly need to,
which he viewed as an inefficient and wasteful allocation of capital. Thats why his paper stumps for
copays and deductibles: raising the point-of-sale costs of going to the physician might make people think
twice before they waste precious resources on a nonailment.
Advocates of preventative medicine actually agree with Mr Pauly up to a point. Both sides recognize that
lower up-front costs promote nonemergent healthcare usage, but see that extra consumption as an
opportunity to identify minor problems before they become major ones. They believe that an ounce of
prevention is worth a pound of cure. Its tough to reconcile the 2 views; you more or less have to pick 1
side or the other.
Exactly what the optimal approach to the opioid crisis looks like has a lot to do with whether its a moral
hazard problem or a preventative medicine problem. Moral hazards call for deterrence, and in those
circumstances, risk mitigation efforts such as increasing naloxone availability only exacerbate the issue
by pushing users toward riskier and risker behavior, meaning that its better to disrupt the supply chain in
the hopes that the drugs never make it to the street in the first place. Connecticut, for example, has
drastically increased its prosecution of low-level opioid retailers, with the intention of making it more
difficult for users to obtain drugs. That makes sense, as long as the opioid epidemic is mostly a moral
hazard problem and if were comfortable regarding narcotic addicts as criminals. In contrast, states such
as Maryland and North Carolina have broadened the availability of naloxone, which is what you should do
if opioids are a preventative medicine problem and its users are patients who should be treated by
physicians. So which is it?
Actually, its both. The study by Ms Doleac and Ms Mukherjee ultimately found that a regions response to
expanded naloxone availability depended largely on the presence of opioid treatment facilities in the
area. In cities with many of those facilities, making naloxone more accessible decreased opioid use and
related crime; in areas with fewer centers, the opposite happened. Its not hard to see why: If there are no
treatment facilities around, an emergency naloxone shot saves a life but also reiterates the availability of
an overdose safety net, and maybe even quietly suggests taking a bigger dose the next time around.
Moral hazard abounds. But if there are treatment beds available, a lifesaving dose of naloxone might well
lead to in-patient rehabilitation, which, in turn, could help break the cycle of addiction before the worst
happens, just as the preventative medicine advocates drew it up. It turns out that the availability of
addiction treatment facilities forms the dividing line between moral hazard and preventative medicine
problems.
And thats where Ms Doleac and Ms Mukherjee and their critics in the medical community see eye to eye.
Dr Faust, the emergency department physician, points out that the treatment goal is to provide [opioid
users] with both short- and long-term treatment options, which certainly means opening more
treatment centers. Meanwhile, the study hes ostensibly criticizing concludes that [i]ncreasing access to
drug treatment, then, might be a necessary complement to naloxone access in curbing the opioid
overdose epidemic. Either way, treatment infrastructure is the key to transforming opioid use into the
kind of problem that physicians, not lawyers and judges, can solve. Opioid users are patients, not
criminals, and doctor knows best.
References
1. Doleac JL, Mukherjee A. The moral hazard of lifesaving innovations: naloxone access, opioid abuse,
and crime [published online September 30, 2018]. SSRN. doi: 10.2139/ssrn.3135264
2. Faust JS. Are we reviving too many opioid overdoses? Is this really a question? Slate.
https://slate.com/technology/2018/03/a-new-paper-suggesting-narcan-might-have-downsides-is-
presenting-an-immoral-case.html. March 8, 2018. Accessed November 6, 2018.
3. Pauly MV. The economics of moral hazard: comment. American Econ Rev. 1968;58(3):531-537.
4. Gladwell M. The moral-hazard myth. The New Yorker.
https://www.newyorker.com/magazine/2005/08/29/the-moral-hazard-myth. August 29, 2005.
Accessed November 6, 2018.
5. Rothberg RL, Stith K. The opioid crisis and federal criminal prosecution. J Law Med Ethics.
2018;46(2):292-313.
TOPICS: MEDICAL ETHICS MEDICINE
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S U B M I T
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Unlimited access to our expert content
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Popular in Medical Bag
Continuing Medical Education (CME/CE) Courses
Higher Vitamin C, Carotenoid Intake May Lower Risk for T2D
The Space Between: Connecting the
Science of Targeted PsA Therapies to
Patient Care
Supporting Patients in the OUD
Treatment Struggle
Reviewing the Rationale for Medication-
Assisted Treatment and Ongoing Support
Addiction Medicine for Non-Specialists
for NPs and PAs
United States
Medicine
Lifestyle
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Finance
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Neurology Advisor
Oncology Nurse Advisor
Psychiatry Advisor
Pulmonology Advisor
Renal & Urology News
Rheumatology Advisor
The Cardiology Advisor
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This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization.
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