Justice, Population Health, and Deep Brain Stimulation: The Interplay of Inequities and Novel Health Technologies

Abstract

This article adopts a population-level bioethics approach to analyzing the ethical implications of novel deep-brain stimulation (DBS) technologies. I claim that a microlevel focus on costs and benefits is necessary but insufficient to address the concerns of social justice and health equity that attend the potential utilization of DBS technologies. A macrosocial, population-based analysis notes two ethically significant trends regarding novel health technologies: (1) that they are the prime mover of hyperinflationary health cost trajectories, and (2) that even where they improve overall population health such technologies may expand health inequalities. Such an expansion could exacerbate what Powers and Faden have identified as “densely-woven patterns of disadvantage,” and therein could contravene mandates of social justice. Such concerns of justice and equity are sharpened by the fact that those populations that bear the highest risk of suffering the injuries and illnesses for which DBS technologies might be warranted are among the most disadvantaged groups in American society. Accordingly, ethical analysis of DBS technologies must include an assessment of the evidence suggesting that in their capacity to improve health and compress health inequalities, whole-population approaches that address the upstream factors that shape distributions of neuropsychiatric injuries and illness may be preferable to acute health interventions. However, the article warns against the false-choice fallacy, and notes that whole-population policies and acute care interventions can be simultaneously endorsed. The article concludes by suggesting that the ethical issue of relative priority between these approaches is best framed via a population-level analysis.

Keywords:

• deep brain stimulation
• depression
• neurodegenerative disease
• neuroethics

Notes

Cutler and McClellan (2001) consider several case studies from which they conclude that the enormous expenditures on health technologies are justified. Similarly, Cutler, Deaton, and Lleras-Muney (2006) argue that the gains in life expectancy are attributable in important part to improvements in health technologies (interpreted broadly). For a variety of reasons, discussion of which is generally beyond the scope of this article, I do not agree with such claims. I will say here that one principal reason for my disagreement is that the authors’ conclusion regarding the relative contribution of technological change to epidemiologic patterns requires methodological controls for a variety of confounding variables that in my estimation cannot be so controlled. Some of these confounding variables—roughly understood as the social determinants of health—are discussed in this article.