Lifestyle changes for treating diabetes: should we be more strict when it comes to the overweight?

Abstract

The past few decades have seen a rise in the number of people who are over- weight and obese in the Netherlands, which has resulted in an increase in people who develop diabetes. In light of the rise in healthcare costs that this brings about and the feeling of injustice when a considerable proportion of public resources are being spent to treat self-inflicted -and thus avoidable- disease, this paper discusses whether compulsory lifestyle treatment combined with a policy of having to pay higher health insurance premiums in case of non-compliance with lifestyle treatment, could help to contain these healthcare costs as well as promote health and quality of life in the overweight. Problems with the current diabetes treatment protocol when it comes to the overweight and obese are discussed, and it is explained how a policy of lifestyle treatment could provide an answer to these problems. Furthermore, the circumstances under which it can be morally defended that people are treated unequally in an (otherwise) egalitarian system are discussed, and this is applied to Dutch health insurance practice. A forward-looking conception of moral responsibility for disease is proposed, which avoids the problems associated with a backward-looking conception of responsibility, such as that people can often not be held fully responsible for their past behaviour. Several problems with the alternative proposal are discussed, such as the risk of undermining the trust between doctor and patient, effective exclusion of health insurance this policy might cause due to high premiums, and the impingement of a person’s autonomy by making lifestyle treatment compulsory for overweight diabetes patients. Also, several unresolved issues are explored, such as whether the costs of lifestyle treatment should be covered by public health insurance when lifestyle treatment turns out to be very effective, but not cost-effective; the question of whether to make lifestyle therapy compulsory for other overweight persons who have not yet developed any overweight related disease and might benefit equally; and whether a similar policy should be applied to other patient groups with self-inflicted disease, and if so, what the results should be when someone belongs to more than one of the patient categories to which this policy is applied (especially with respect to higher insurance premiums)?