The ethics of genetics against the little man - either the client will die, or the insurance company will die
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The genetic tests that today make it possible to discover genes that cause dangerous diseases have changed our relative uncertainty regarding our personal genetic content. Until recently, if such a gene was discovered in the tests you underwent, you were not obliged to reveal it to anyone, except in extreme cases. But this month, Britain became the first country in the world to allow life insurance companies to demand the results of the tests. In the meantime, the approval is only given for tests to identify a degenerative brain disease called Huntington's disease. But ten other tests (to test for seven additional diseases) are awaiting similar approval.
The body that issues the certificates, the Genetics and Insurance Committee in the British Ministry of Health, does not have to decide whether the use of genetic information for insurance purposes is ethical. He must judge only if the tests are reliable and relevant to the insurance companies. In the case of Huntington's disease, the answer is an unequivocal yes. People who are lucky enough to get this gene will die young and will cost the insurance companies dearly.
this is only the beginning. Today unequivocal genetic answers, those in which a certain gene is directly linked to the risk of death, are not common. But as tests improve, it will be easier to predict whether a particular person is at risk. In the coming years, human genome researchers will discover more and more the action of individual genes, and what health risks (or benefits) are associated with them. The technology of DNA chips will create a revolution in genetic tests; It will allow you to search many different genes at the same time.
What does it mean to provide access to the results of such tests to life and health insurance companies? The common perception is that this will be good news for the insurance companies, who will be able to avoid insuring high-risk individuals (or at least demand much higher premiums); And bad news for consumers, who will refrain from testing if they end up having to pay more. But in fact, the insurance companies have equally good reasons to fear the advancement of technology.
Today, most governments restrict or prohibit the use of information from genetic testing. The legislation in the US is not yet federal, but insurance companies in 18 states cannot withhold insurance from those who apply to them, cancel their policies or demand higher premiums based on the client's genetic load. In Austria, a law prohibits insurance companies and employers from using the results of genetic tests. In France, the Federation of Insurance Companies (whose membership is not mandatory) announced the avoidance of any use of such tests, for five years.
Such restrictions spell trouble for insurance companies. At the moment, the principle of "absolute good faith" requires everyone who applies to the insurance company to disclose any relevant information to the insurer; False information leads to the cancellation of the agreement. Allowing the non-disclosure of a major risk component, such as the result of a genetic test, would undermine one of the principles underlying insurance.
A person who knows (following an examination) that he will die in the next two years, can insure himself for a huge amount and sell the policy to a third party. Similarly, if insurance companies no longer knew the results of genetic testing, people at higher risk would be able to buy more insurance and insure larger amounts, while those at low risk would buy less insurance. "Non-disclosure of genetic test results can eliminate the life insurance market," says Achim Wambach, an economist at the University of Munich.
Therefore, it is likely that most countries will follow the UK and allow insurance companies to consider genetic testing. "If the information exists, eventually it will be used," says David Schiff of "Schiff's Insurance", an insurance magazine. But also an obligation to provide the results of the tests will cause tremendous changes in the insurance industry.
The insurance is based on the logical idea that the risk must be shared through the insurance of many people. The insurance companies rely on the fact that the payments to the policy holders that occurred unexpectedly are offset by the premiums of the others. In a world of uncertainty, private individuals are happy to cooperate and share their risk with others. But the genetic tests promise to greatly reduce the degree of uncertainty. Those whose genetic fate has favored them will choose not to share the risk with others; Those whose genes are cataloged as the worst will find that there is no one to insure them, and the insurance market will shrink.
Therefore, the governments have a choice: ban the use of the test results and destroy the insurance industry, or allow their use and create a subclass of people that no one is willing to insure, or who cannot afford insurance. And it's already happening: even without genetic testing, people with a family history of Huntington's disease have a very hard time getting life insurance.
It seems that governments will eventually have to provide some sort of safety net for the high risk. In fact, genetic testing may become the strongest argument in favor of universal state health insurance.
At the moment these tests are still taking their first steps. A better understanding of the genetic basis of diseases promises to revolutionize medicine in the coming years. But the consequences for private and public health insurance will be no less dramatic.
(Originally published in The Economist on 21.10)
{Appeared in Haaretz newspaper, 30/10/2000
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