Hedging Their Bets

Predictive medicine--monitoring and even treating potential illness in people who are asymptomatic--holds the promise of transforming health care. Armed with foreknowledge of individuals' particular susceptibilities, physicians will be able not only to intervene before disease takes its toll but also to tailor the advice they give patients about diet and life-style, focusing attention on the salient measures that now get lost in the deluge of generalized guidance and admonitions. Yet this new field holds peril as well as promise since findings about disease susceptibility may interest people other than the ones being tested. Indeed, the possible interest of insurance companies in such data has been a point of concern for those who see a double-edged sword in the techniques being developed by the genome mappers and others on the frontiers of molecular medicine.[1] Recently, several states have responded by enacting legislation to restrict the uses that insurers can make of "genetic information." In opposing such laws, the insurance industry has claimed that they are unnecessary because insurers have no plans to make use of genetic tests now. The concern that genetic results will render some people unable to obtain health insurance reflects underlying problems in health care coverage and would best be addressed as part of current efforts to reform access to health care generally. Nonetheless, one major life insurance company's wholesale use of an experimental screening test not only suggests that at least some insurers are interested in predictive medicine but also raises questions about how reliability data for such screening devices will be gathered. On 14 January 1993 the California Department of Insurance opened an investigation of Transamerica Occidental Life Insurance Company's use of a new blood test for cancer antibodies to screen over 50,000 applicants over the previous two years.[2] The department is looking into allegations, denied by the company, that the test was used to rate or deny applicants for insurance policies. The willingness of Transamerica to use a test characterized by a scientist at the National Cancer Institute as unreliable and inappropriate for screening throws doubt onto the insurance industry's insistence that genetic tests are not being used since they are obviously still just experimental. The company--like any thinking of adopting a new screening tool--understandably wanted to be able to track whether the test provided reliable information for underwriting purposes. But the situation is complicated for Transamerica because it owns 30 percent of the laboratory that developed the test and hopes, if the test pans out, to market it to other insurers. Thus it appears to have used its applicants as experimental subjects. Furthermore, the company admits that applicants were not told about the test but merely signed forms consenting to blood tests for "tumors." Again, this is problematic for Transamerica because California is one of the few states with a statute that establishes standards for human experimentation.[3] That statute requires explicit, written informed consent after subjects have been given a copy of the "experimental subject's bill of rights." It would be surprising were insurers totally uninterested in the torrent of predictive tests that the life sciences are starting to unleash. Some tests rely on older methods, such as antibody detection, but the most eagerly awaited are those that look for genetic variation at a molecular level rather than searching for cellular products. While many genetic conditions are so rare that population screening may never be practical (unless technical advances reduce the cost to pennies per test), some diseases are more common, and even for rare ones a genetic test may be justified economically when an applicant wants a very large policy. Recognizing that premature death or severe illness could have a catastrophic effect on their families, people are willing to pay a small amount to cushion the financial consequences of misfortune. …