Running head: BIOETHICAL PRINICPLE PAPER 1

Bioethical Principle Paper: The Rise of Insulin Prices

Jonathan Rodriguez
Azusa Pacific University
GNRS 504: Bioethics and Healthcare Policy
August 3, 2020
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Bioethical Principle Paper: The Rise of Insulin Prices

Introduction

A 25-year-old Latino man was brought in by ambulance to a community hospital

emergency room complaining of nausea, abdominal pain, and vomited twice that day. The

paramedics reported that the patient had a blood glucose level of 550 mg/dL on scene. Upon

assessment the patient had fruity-scented breath and appeared fatigued, diaphoretic, and

confused. After labs and urinalysis returned, the patient’s admitting diagnoses was diabetic

ketoacidosis (DKA) and was treated with insulin. When the nurse returned to reassess the

patient, they found the patient crying and frantic. The nurse calmed the patient and he admitted

that he is a type 1 diabetic. He has been taking insulin up to three times a day since he was seven,

but a week ago he began rationing his insulin supply and ran out two days ago. The patient stated

that he could not afford the insulin vials. Some might think that this scenario does not occur that

often in the United States of America (USA), but according to Herkert et. al.’s study, 25% of the

patients with diabetes mellitus (DM) that participated in their survey reported cost related

underuse of insulin (2019). In another study, Yan et. al. conducted a one-year health record

review study and found that of the 1,148 hyperglycemia related emergency room visits, 28.9%

were caused by underdosing of insulin (2017). This is a serious issue because about 25% of the

population with DM that use insulin, around 7.4 million people (Center for Disease Control and

Prevention, 2019) are at risk for developing DKA, which is fatal. According to Basu et. al, 3.9 %

of hospital mortality rate was associated with DKA (1993). In the next paragraph the

development of DM will be explained and how it is life threatening.

There are two types of DM. DM type 1 is when the patient is genetically predisposed

meaning that an individual’s own autoimmune T-cells destroy the insulin producing beta cell
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from the pancreas (Huether & McCance, 2017). DM type 2 is when an individual’s risk factors

result in insulin resistance and then the body tries to compensate by causing hyperinsulinemia.

Hyperinsulinemia is when the pancreas produces too much insulin to compensate for the

excessive amount of sugars being consumed. Over time the hyperinsulinemia will result in

pancreatic beta cell dysfunction (Huether & McCance, 2017). Both types of DM will result in the

patient requiring exogenous insulin to allow glucose in the blood stream to enter the cells.

Without exogenous insulin the patients will experience ketoacidosis; when the body builds-up

toxic ketones that cause confusion, comatose, and can lead to death. Individuals with DM can

manage and control their blood glucose levels with insulin, however when insulin is not

affordable, then death is inevitable if they do not seek medical attention immediately.

According to Wineinger, Zhang, and Topol’s study on trends of popular prescribed

medication cost, it was found that on average insulin prices from 2012- 2017 had increased by

more than 100% (2019). For example, the price of Humalog in 2012 was $126 for a month

supply and by 2017 it was $274 for a month supply, a 117% increase (Wineinger, Zhang, &

Topol, 2019). The current retail price for a month supply of Humolog is $520.40 according to Eli

Lilly’s insulin company (2020). Wineinger, Zhang, and Topol mention that “for those among the

12.1% of uninsured or underinsured adults, out-of-pocket costs can be crippling or catastrophic”

(2019, p. 10). Another study states that the price of all insulins has increased 10% per year since

2009 (Cefalu et. al, 2018). The increase of insulin prices can affect people that are uninsured or

even those that are insured but have maxed out on their deductible. With these prices, it is no

surprise that a lot of individuals with diabetes have a hard time affording their insulin and must

start to ration. This paper will discuss the ethical theories and principles that revolve around the

rise of insulin prices, such as the Utilitarianism, Kantianism, virtue theory, and the principle of
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non-maleficence. This paper will also discuss how cultural dynamics have been affected as well

as the nurses’ professional position on the issue. Insulin is a lifesaving saving medication and

there is no reason that any diabetic should have to take less insulin than prescribed just because

they cannot afford it. This issue has caught the attention of the USA’s government; policies and

acts have been introduced but there has not been any affirmative decision on how to address this

issue at this time. My suggestion would be in favor of the House of Representative’s approach on

the issue, to negotiate a price of medications, such as insulin. Until that act has passed, nurses

must provide resources and education for the patients with DM so they could afford their

medication.

Ethical Theories and Principles

As mentioned above, insulin is a life-saving medication that is essential for patients with

DM, but it has been affected by corporate greed via price gouging. The increase in insulin prices

violates several ethical theories and principles: utilitarianism, Kantianism, virtue theory and the

principle of non-maleficence. The following paragraphs will explain how the increase of insulin

price violates the ethical theories and principles.

Utilitarianism. Pharmaceutical corporations that produce insulin do not abide by the

utilitarian belief, which is to produce the greatest good for the greatest number or by producing

the least amount of harm (Beauchamp & Childress, 2013). The stakeholders that are mainly

affected by price gouging of insulin are the consumers that rely on it to live. The decision to raise

the cost of insulin does not produce the greatest good to the greatest number. On the contrary, it

inflicts harm because now the consumers must decide whether to buy lifesaving medication or

skip a meal, which is also not advised for a DM. Another effect that the decision to raise insulin
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prices creates is that of rationing their insulin supply. The result of rationing is detrimental to the

health of diabetics because it places them at risk of diabetic ketoacidosis and potentially death.

Kantianism. Kantianism is another applicable ethical theory to the issue of raising

insulin prices. Kantianism allows individuals to make rational decisions, not decisions based on

consequences or emotions, but on good intentions. Beauchamp and Childress state that “human

beings are creatures with rational powers that motivate them morally, that help them resist

tempting desires, and allow them to prescribe moral rules to themselves” (2013, p. 362). In the

ethical issue that is being discussed, the individuals are the leaders of the company that are

expected to make the rational decision. The companies’ leaders are not following Kantianism

practice because they are not demonstrating good intentions and instead are making decisions

that are harming the consumer. The consumers are being disrespected and taken advantage

because they depend on insulin to live. Individuals are forced to buy the overpriced insulin

because they have no other options.

Virtue Theory. Virtue theory asks the individual, or in this case the leaders of the

companies, to reflect and ask themselves “what morally ought to be done” (Beauchamp &

Childress, 2013, p. 375)? The result of the virtue theory is an action that is not motivated by

personal gain but is motivated to promote the wellness to others. It focuses on human

relationships as being important and focuses on the beneficence of others without the concern of

consequences (Beauchamp & Childress, 2013). Pharmaceutical companies fail to follow an

action that is motivated by wellness and thus lack justice, and care. In no way do the leaders of

the pharmaceutical companies focus on the beneficence of the consumer when they keep raising

the price of insulin. Greed is the biggest influence that motives companies to decide on unethical
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decisions. The motivation is to obtain the most profit without consideration of how it affects the

consumer, the human relationship.

Non-maleficence. The final ethical principle that will be discussed is that of non-

maleficence. Under the principle of non-maleficence, everyone is required to act in way that

harm does not occur to another. The leaders of the pharmaceutical companies that produce the

insulin are not acting with non-maleficence because by raising the price of insulin they are

causing harm to their consumers. The consumers must ration their insulin supply and hope they

make it to their next supply before any detrimental effects occur, such as ketoacidosis. Another

alternative is to buy the expensive insulin supply and put off paying rent or buying groceries.

The increase of insulin prices has affected a wide range of people.

Cultural Dynamic

A culture can be defined by customs, beliefs, and collective identity that is shared

between a group of people (American Sociological Association, 2020). Although the cultures

that are affected by the increase in insulin prices might not reflect the norm of a cultural groups,

they are a culture because they are a group of individuals that face similar hardships, and have to

perform similar customs to survive. The cultural groups that are most affected by the increase in

insulin prices are the uninsured or underinsured, the impoverished, and minorities.

Uninsured and underinsured. As Wineinger, Zhang, and Topol have mentioned, 12.1%

of the USA population is uninsured or underinsured (2019). An uninsured individual will have to

pay the full list price of insulin. For personal reasons, several individuals from the USA decide to

go uninsured, but the estimated yearly 10% increase of the price of insulin is not sustainable with

the average yearly 3% pay increase of an employee (Morris, 2019). At a certain point, the

uninsured individual will not be able to afford their supply of insulin, which leads to deciding to
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ration or go without paying rent or groceries. Although there are several patient assistance

programs and reimbursements, patients will have to be eligible based on income. It is a broken

system in which majority of Americans make too much to qualify for assistance, but do not make

enough to afford their medications.

According to Cefula et. al., although the underinsured do have insurance, they will need

to pay the full list price of insulin until they reach the annual deductible (2018). Even after they

reach the deductible the individual will most likely pay a co-payment per prescription, which is

manageable if it was not for the individuals also having to pay a percentage of the full price

(Cefula et. al., 2018). Even individuals that are insured do not escape the risk of not affording

their insulin due to the price increase.

Impoverished. In 2018, 11.8% of the USA’s population lived in poverty (poverty.org,

2020). Having DM while also living in poverty can be catastrophic because now, this group must

determine what takes priority in essential items, medication versus food and shelter. This cultural

group is already fighting to survive and live with their uncurable disease. On top of trying to

manage their disease, but with increasing prices of insulin yearly, which is an increase that does

not reflect the consumers raise in yearly income as mentioned above, the individuals with DM

tend to ration their medication and are hospitalized with DKA more often (Yan et. al., 2017). Not

to mention that hospital fees can also be financially crippling to these individuals, but some

individuals take the risk of ending up in the hospital because they have no other options.

Minorities. If it wasn’t already hard to be a minority in the USA, these individuals also

have to manage with having DM. Minority groups do not need another obstacle, such that

increasing price of insulin, impeding them from thriving in a system that has already oppressed

them. Minority groups are the cultural groups that are affected the most by the increase of insulin
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prices because 25.4% of Native Americans, 20.8% of African Americans, and 17.6 % of

Hispanics live in poverty (povertyusa.org, 2020). Furthermore, 18.7% of African Americans,

16.1% of Native Americans, and 11.8% of Hispanics have DM (Chow et. al., 2012). Native

American, African Americans and Hispanics are 2.3, 2.0 and 1.5 times more likely to die from

DM compared to a non-Hispanic white individual and this might be because these minorities

groups are the highest prevalence group of having diabetes and also the highest living in poverty

(Chow et. al., 2012). Essentially, minorities cannot afford their life saving medication due to the

unethical price increase of insulin.

Nursing Code of Ethics and Nurse’s Position on the Issue

The Nursing Code of Ethics was made to serve as a statement of the ethical obligations

and duties for people that enter the field (Fowler, 2015). Although not directed towards the ethics

behind the increase insulin prices, there are provisions in the nursing code of effects that can be

applied. The nursing code of ethics reflect the nurse profession’s position of the unethical issue.

Provision 3. Provision 3 states, “the nurse promotes, advocates for, and protects the

rights, health, and safety of the patient” (Fowler, 2015, p. 65). The nurse is responsible to

advocate for the safety of their patients who are affected by the increase rise of insulin prices.

Specifically, provision 3.5: To Protect Patient Health and Safety by Action on Questionable

Practice states, “the nurse acts to safeguard the client and the public when health and safety are

affected by the incompetent, unethical, or illegal practice of any person” (Fowler, 2015, p. 66).

The nurse needs to demonstrate beneficence, and act to protect the patients against unethical

actions.

Provision 2. Provision 2 states, “the nurse’s primary commitment is to the patient…”

(Fowler, 2015, p. 46). The nurse’s loyalty belongs to the patient and not to competing loyalties,

such as loyalties to the employed hospital or the pharmaceutical companies (Fowler, 2015). The
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nurse is responsible to act within an ethic to care (Fowler, 2015). The nurse acts in the patient’s

best interest and outcome, and when the patient’s interest and outcome are being negatively

affected, such as the patient with DM not being able to afford their insulin, then it is the

responsibility of the nurse to intervene and find a solution that can benefit the patient.

Nurse’s position. The provisions of the Nursing Code of Ethics mentioned above are

important because it allows nurses to transform the health care system. Nurses are witnesses of

the negative effects caused by increased prices to medication, such as insulin, towards patients.

Nurses treat the patients with DM at the emergency room for hyperglycemia and DKA. The

nurse’s intervention is to seek guidance from social workers to find resources for these patients.

The nurse’s position on this issue is that this type of unethical decisions by pharmaceutical

companies needs to be regulated or stopped for the sake of the patient’s health. Nurses can make

a difference for their patients by being advocates and speaking on their behalf to form and

change policies that will secure people with DM their insulin at an affordable price.

Policies
The leaders of the pharmaceutical companies need to be held accountable and change

policies in a manner that represents the principle of non-maleficence. If it is not the leaders of the

pharmaceutical companies than as a nation, the citizens need to implement change and promote

new policies that protect the individuals that depend on medications, such as the people with DM

that depend on insulin, to live. Both the House of representative and the Senate acknowledge that

medication prices continue to rise but they differ on how they want to combat the issue.

Elijah E. Cummings Lower Drug Costs Now Act (H.R. 3). H.R.3 is an act that was

passed by the House of Representatives last December but has not yet been passed by the Senate.

The goal of this act is to establish a fair price negotiation program and protect consumers from

excessive price increases (Pallone, 2019). The act negotiates lower prices for high priced
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medication, including several insulin products. The price of the medication can not exceed 120%

of the average international market price. Manufactures would be penalized for providing a price

that is higher than the requirement (Pallone, 2019). The senate argues that H.R.3 is flawed

because it requires the government to interfere with the private sector (Pallone, 2019). Such

interferences would discourage pharmaceutical innovation and thus slow down the production of

life saving medicines. The Senate is assuming that the pharmaceutical companies are greatly

influenced by profit rather than doing good. Although pharmaceutical companies have

demonstrated that they are influenced by profit, placing a fair price negotiation program would

not deter them from continuing research for live saving medication.

Prescription Drug Pricing Reduction Act of 2019 (S. 2543). S. 2543 is an act that was

introduced by the Senate in September with a goal to lower the out of pocket cost for

medications, meaning that initially the individual will have to be insured (N.A., 2019). In no way

does this act lower the price of the medication. This act encourages pharmaceutical manufactures

to increase rebates on their medication. The Senate is missing the main point that certain

medications are overpriced, increasing yearly and that some citizens are uninsured.

Personal View
I believe that people should treat others the way they would like to be treated. This is not

happening when pharmaceutical companies are exploiting diabetics’ that are dependent on

insulin to gain profit. People should speak up against injustice and advocate for those that

cannot. There should be a limitation in the profits that pharmaceutical companies obtain because

the life of another person should not be profitable. The goal of pharmaceutical advancement

should not be to make the most profit but improve the quality of life of a disadvantaged

population.

Suggestions
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Nurses have an important role to act as advocates for their patients and try to create

systemic change via reform or changes in policies, but they cannot forget about what can be done

now for the patients in need. Some suggestions would be to be available for the patient and

participate in active listening to discuss financial hardships in affording insulin. Nurses should be

prepared to find resources for patients that are having a hard time affording their medication,

such as support groups or having the patient consult with a social worker. Nurses cannot forget

to educate their patients on the dangers of rationing insulin and how in can lead to death.

Conclusion
Overall, the decision to increase insulin prices is unethical as explained through the

theories of Utilitarianism, Kantianism, Virtue theory, and the ethical principle of non-

maleficence. The cultural groups that are directly affected by the increase of insulin are the

uninsured and underinsured, the impoverished, and several minority groups. Under several

provisions in the Nursing Code of Ethics, it the nurse’s responsibly to advocate, remain loyal,

and protect the patients regardless if it hinders the relationship with the hospital because the

relationship with the patient takes priority. The increase of insulin and other medication has been

acknowledged by the House of Representatives and the Senate, and hopefully soon there will be

change and formation of policies that help patients with DM get access to affordable insulin.

Insulin is a lifesaving saving medication and for no reason should a person with DM take less

insulin than prescribed just because they cannot afford it.

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