Turning a Blind Eye?
by Jeffrey P. Kahn, Ph.D., M.P.H.
University of Minnesota
I have terrible eyesight. I'm extremely nearsighted ("minus" numbers in the double digits) with a touch of astigmatism thrown in. Luckily, I was born in the 20th century, where with benefit of eyeglasses, or better yet, contact lenses, I have perfectly "normal" vision. And now with the help of refractive surgery, I can have my eyes permanently fixed by a procedure to flatten out their misshapen lenses.
What would this do for me? I could see the alarm clock at night without putting on glasses and wouldn't have to worry about that grit that lodges between my eye and the contact lens when the wind kicks up. But more seriously, corrective eye surgery might keep my eyes from tiring as early late at night, and would certainly enhance my ability to swim and do other things that are limited by worrying about losing contact lenses or don't lend themselves to eyeglasses.
Achieving this newfound normalcy doesn't come free or cheap, however. The price will probably come down as more ophthalmologists gain expertise and the specialized equipment becomes more widely available, but now it costs thousands of dollars for any of the available vision-correcting procedures, and so far insurance companies do not cover the cost.
Optional benefits carry required risks
One reason payers are reluctant to cover such procedures is to control costs by making a distinction between necessary and optional treatment. But even if individuals can afford their cost, these procedures carry some risks -- infection, failure to improve vision, even permanent damage to the eyes can all result, albeit at very low probability. How much risk is too much to accept for what might be considered optional treatment?
Living in an era of enhancement
Sometimes medicine can cure, treat or prevent illness and disease, and other times it can enhance our abilities -- all with some risk. We need to decide what counts as curing disease or disability and what amounts to enhancing function that lies somewhere in the normal. Then we must decide whether to treat curative technologies differently from those that enhance, say by limiting access or by requiring individuals to bear their cost. Our public policy has largely been to allow new technologies onto the market so long as their risk is acceptably low and they work, and then let insurance companies and individuals decide how to pay for them. This basic approach is already being tested by lifestyle-enhancing drugs and technologies that grow hair, improve mood and sex life, or repair poor vision.
Are breakthroughs like these what we need to be healthy and function better, or are they just another form of cosmetic surgery? Do they offer important improvement, or enhancements that we didn't know we needed and whose risks we didn't have to bear until they became available? How far should such enhancements be taken: Why not use the same surgery to give people better than normal vision, or implants for more acute hearing or to make taste buds more sensitive? There are no easy answers, but we are beginning to appreciate that half the challenge of medical advancement is developing new techniques and approaches, and the other half is knowing when to use them.
With new refractive surgery, poor eyesight can be fixed permanently. However, it is expensive, carries some risk and offers benefits many consider optional. Are breakthroughs like these what we need to be healthy and function better, or are they just another form of cosmetic surgery? How far should such enhancements be taken? Why not use the same surgery to give people better than normal vision, or implants for more acute hearing or to make taste buds more sensitive?
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"Ethics Matters" Archive
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