Access to Insulin
The Role of Insulin
The question we have been considering, “Who should receive the flu vaccine?” is a question that asks us to decide how we should manage access to a resource. This type of question can be applied to many topics, from organ donation to allocation of natural resources.
We are now going to ask a similar question about access to insulin. “How should insulin be made available to people who need it?”
Unlike flu vaccines, the factor that limits access to insulin for most people is cost. In this case, we will consider who is being harmed, who is benefitting, and what are our individual and collective responsibilities.
First, let's learn about insulin's role in the body. People living with diabetes rely on insulin to regulate their blood sugar (glucose) levels. Insulin is a hormone produced by the pancreas. It allows glucose to leave the blood and enter the cells to be used for energy. Glucose that does not enter the cells stays in the blood. Without insulin, high levels of blood glucose can damage nerves, and small and large blood vessels. This can impact:
The EYES, leading to blindness
The FEET (limbs) leading to amputations
The HEART, leading to heart disease and heart attacks
The KIDNEYS, leading to kidney failure
….and other complications, even leading to death
People with diabetes are also at an increased risk for severe illness from COVID-19.
Watch the next video to learn more about diabetes and insulin. (2:05)
What is the difference between type 1 and type 2 diabetes?
With type 1 diabetes, a person's pancreas does not produce insulin. People with type 1 diabetes need to inject insulin to keep blood glucose levels within a healthy range. Type 1 diabetes accounts for about 5% of the cases of diabetes.
With pre-diabetes or the early stages of type 2 diabetes, a person's pancreas makes insulin but the cells of the body do not respond well to the insulin. This is called insulin resistance. Insulin resistance causes glucose to build up in the bloodstream, which makes the pancreas works harder and harder. Over time, insulin production fails. At this point, people with type 2 diabetes need to inject insulin, just like people with type 1 diabetes. Type 2 diabetes accounts for 90-95% of the cases of diabetes.
While over 95% of people with diabetes have type 1 or type 2 diabetes, people also experience gestational diabetes, different types of Mature Onset of Diabetes in Youth (MODY), drug-induced diabetes, and other conditions that lead to high blood glucose levels.
The Cost of Insulin
The next story may be hard to hear. It is the real story of a family’s lived experience, which may be upsetting. It will hit people differently based on their own personal experiences with type 1 diabetes, loss, and health challenges.
Watch this video clip from the PBS special Blood Sugar Rising about the Smith-Holt Family.
In the 1920s, the scientists who found and purified insulin sold their patent for $1 to make sure the hormone would be available to all. But today, for patients without good insurance, the drug can cost hundreds of dollars a month. What does a person do when he can’t afford this life-saving medication? For the Smith-Holt family, the answer came down to a tragic choice.
If you would like, you can make some comments on the Jamboard.
Why is insulin so expensive?
Video clip: The Cost of Insulin
In the past few decades insulin prices have skyrocketed. Watch this clip, from the PBS special Blood Sugar Rising, to find out more about how the prices for insulin are set, the finger-pointing taking place between the manufacturers and pharmacy benefits managers, and how those with no insurance must pay the price.
In 2021, eight states have placed caps on insulin prices. However these benefits generally apply to people with health insurance.
Who are the Stakeholders?
Stakeholders are individuals or groups of people who are affected by the outcome of a situation. Stakeholders care about the outcome because it will affect them in some way—they have a stake in what happens.
Stakeholders may come from different backgrounds or have different perspectives on the cost of insulin. They come with their own values, biases, and priorities.
Who is impacted by insulin production and access? What does each person or group value? What are their concerns?
Here are some people or groups who are stakeholders in the price of insulin.
Choose four stakeholder groups.
You will be asked to write down potential concerns or values for four different stakeholder groups. Here is a list of values that might help you determine what is important to each group. Do those values align with any of the ethical principles we've learned about?
Using an Ethical Framework to Justify Decisions
Here are the Ethical Principles put forth by the National Academy of Sciences to help with decisions about a COVID-19 vaccine, but tailored towards insulin.
We will add two widely accepted ethical principles to the list:
Ethical Principle:
Respect for Persons
What it is:
Autonomy
What this means:
Acknowledging a person's right to make choices, to hold views, and to take actions based on personal values and beliefs.
Ethical Principle:
Care
What it is:
Considering relationships and understanding power structures
What this means:
Identifies vulnerable populations, looks at how underlying structures may drive a situation. Asks: Who is being ignored? Who is benefitting? At whose expense? Who has resources, such as money, insurance, and time?
