Somewhere near where you live, a couple will discover this week that they are infertile and that if they want biological children of their own, they are going to need in vitro fertilization (or IVF). According to treatment protocol, the woman will need to take powerful medicines to ramp up her production of fertilizable eggs. One monthly cycle of this treatment will run around $12,000. But most couples require more than one cycle to achieve their goal of carrying a child to term. In other words, this couple could easily be looking at a bill exceeding $30,000 or $40,000.
And did I mention that this money could all come out of their own pockets?
Because not all insurance companies pay for in vitro fertilization.
No worry though. Their infertility physician informs them about a company he has worked with that specializes in infertility loans. He even offers to have his office staff help the couple fill out the necessary paperwork. Thanks to this assistance, the couple secures the loan and, with luck, will soon be rewarded with a healthy baby.
Free market medicine at its finest, yes? A couple with “skin in the game” learns about their health costs in advance. They are given accurate data about the likelihood that any given cycle of treatment will work. They even work with a loan agency specifically geared to meet their financial needs.
Would it bother you if you learned that the infertility doctor received a referral fee from the loan agency? Would you be upset to learn that this couple was charged an annual interest rate of 22%?
There are lots of reasons to worry that doctors and bankers are taking advantage of couples who are desperate to become pregnant. For starters, those of us who work in behavioral economics recognize that emotions—“I’ve just got to have a baby!”—can stand in the way of rational decision making. Even honest communication about the odds of treatment success—“You have a 10% chance of becoming pregnant in the first round of treatment”—get reinterpreted by couples whose unconscious psyches refuse to hear bad news: “He says 10%, but I know our odds are better than that!” As I point out in Critical Decisions:
“Good decision making is not merely a matter of comprehension. Understanding doesn’t necessarily lead people toward making rational choices. Decision making is often as much about feeling as it is about thinking.”
In the case of couples’ struggling with fertility problems, all these emotions push them toward believing their odds of pregnancy will be greater than average.
Infertility loans are even more problematic when they are suggested to patients by physicians who doubly benefit from such loans. The patients recognize that their physicians make money by providing them treatments. This conflict of interest is inherent to fee for service medicine. All else equal, a fertility specialist who treats 600 couples a year should make more money than one who treats 400. This conflict of interest is a problem, as it can influence physicians both consciously and unconsciously, to offer more treatment than is medically necessary. But there aren’t a whole lot of great alternatives to such conflicts.
In the case of these loans, however, some physicians are carrying an additional conflict of interest. These doctors get kickbacks from loan companies when they refer clients. Should that trouble us?
When I borrow money from an automobile dealer to purchase a car, I realize they are making money not only by selling me the car, but also by giving me the loan. But in the case of fertility treatments, physicians are rarely up front with their patients about their financial interest in getting them to borrow money. And I expect most patients have no idea that some doctors are working out these kinds of financial arrangements. At a minimum, physicians need to be up front about this conflict of interest when it exists.
But even with such disclosure, the fertility case differs in another important way. Physicians are trained to be patient advocates, training that despite its enormous costs is partially subsidized by public funds. Physicians are sworn by oath to look out for their patients’ best interests. They are endowed with specialized knowledge, and commensurate responsibility, with the understanding that patients will come to them in time of need knowing they can count on the doctors for good advice.
Let me be clear: I am not—repeat: not!—calling on the government to regulate the fertility loan market. While I think we need sensible rules to help consumers understand their loans, not just fertility loans but other types of loans too, we don’t need special legislation to protect infertile couples from predatory doctors.
Instead, we need physicians to reflect upon their long established moral duties. So fertility doctors, please: If you want to help your patients, if you plan to advocate for their best interests, don’t muck up the situation by becoming party to the profits made by loaning money to these same patients.
Don’t let your interest in the bottom line cause your morals to bottom out.
Peter Ubel is a physician, behavioral scientist and author of Pricing Life: Why It’s Time for Health Care Rationing and Free Market Madness and his new book Critical Decisions. He teaches business and public policy at Duke University. You can follow him on his personal blog.