From Each According to His Ability, to Each According to His Gene

Posted on | December 29, 2007 | Comments Off on From Each According to His Ability, to Each According to His Gene

Imagine a day when a genetic test not only will determine your risk for a particular disease, but also the ideal medication and the ideal dose to treat that disease.

For those who receive a blood-thinning agent called warfarin, that day has already arrived. One third of people who receive warfarin, known by the trade name of Coumadin®, metabolize the drug differently from the rest of the population. A genetic screening test can identify those individuals who are more prone to bleeding when taking warfarin.

Earlier this year the FDA required a change in drug labeling to advise patients and doctors that a genetic test could identify that subgroup of people at greater risk for bleeding after taking warfarin.

So what does this advance in genetic screening have to do with the current debate about health care reform? A commentator in the Dec. 12 issue of JAMA argues advances in genetic screening and genetically directed treatment are pushing health insurance to a moral precipice.

James P. Evans, MD., Ph.D, a professor of genetics at the University of North Carolina at Chapel Hill, writes that modern health insurance is premised on the assumption that you can accurately predict aggregate risk, but not as easily predict individual risk. As scientists develop more sophisticated genetic tests, the prediction of individual risk will become easier. Insurance companies then would be able to cherry pick those at greatest risk and either deny them coverage or make coverage more expensive.

To prevent that, the U.S. House of Representatives passed the Genetic Nondiscrimination Act of 2007 (GINA) in April. The legislation has yet to pass the Senate. Even with passage of this act, Evans argues that individualized medicine will shift the burden of inequity back onto insurers by allowing individuals to choose coverage based on their specific risks. “Either way, the foundation of the system is undermined: the solution is for all to pool their risks,” Evans writes.

Without a universal health care system, the uninsured will not benefit from genetic screening and individualized treatment. That will lead to even greater disparities in health care delivery between the haves and the have nots. Pharmaceutical companies will have incentives to develop genetically engineered drugs (in a process scientists call pharmacogenomics) for those who have the means to pay for them. Those without insurance or with second-tier insurance won’t have the benefit of the latest advances in drug therapy.

So, advances in pharmacogenomics combined with inequitable distribution of treatment options will result in a rationing of genetically derived drugs. Evans argues that this disparity will lead to a genetic underclass. To prevent that, Evans writes, “… it will be necessary to share risks and pool resources to ensure that, regardless of genetic makeup, a humane and basic level of medical care will be available to all.”

For those who don’t have a family history of diabetes, heart disease or cancer, don’t think individualized medicine won’t benefit you. Evans reminds us that every individual has mutations in his or her genetic code. You may just need to wait until you’re old enough for that mutation to manifest itself.

“This inevitable bad news for individuals is actually good news for the common lot and represents a compelling inducement to share risk,” Evans writes. “Because all are flawed at the level of the genome, all people need each other.”

(Tom Linden, MD, is a professor of medical journalism at the University of North Carolina at Chapel Hill. He can be reached at [email protected]. Opinions expressed by Health Commentary guest bloggers do not necessarily represent the views of Health Commentary.)