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'A few drugs - such as beta-blockers, statins and glycogen control medications - have proved very effective at managing hypertension, heart disease, diabetes and strokes. Most insurance plans charge something for them. Why not make drugs like these free? Not for everyone, but just the groups for whom they are provably effective. In traditional economics, such a policy creates waste. The basic principle is moral hazard: consumers overuse goods that are subsidized. But people don't always follow a cost-benefit logic. The problem is basic human psychology. Heart disease is silent, with few noticeable symptoms. You feel fine most of the time, so it's all too easy to justify skipping the statin. The problem here is the exact opposite of moral hazard. People are not overusing ineffective drugs; they are underusing highly effective ones. This is a quandary that ... call "behavioral hazard." We've found that co-payments do not resolve behavioral hazard. They make it worse. They reduce the use of a drug that is already underused. My proposal is targeted: Take drugs that are shown to be of very high benefit to some people, and make those drugs free for them. All co-pays should depend on measured medical value; high co-pays should be reserved for drugs and medical services that have little proven value. Why not focus instead on the behaviors - eating unhealthy foods or shunning exercise - that created the conditions we must now treat with drugs? [This]has some merit. But [it] fails the "perfect as the enemy of the good" test.

"[I]f our brain's chemistry does affect our moral behavior, the question of whether that balance is set in a natural way or by medical intervention will make no difference in how freely we act. If there are already biochemical differences between us that can be used to predict how ethically we will act, then either such differences are compatible with free will, or they are evidence that at least as far as some of our ethical actions are concerned, none of us have ever had free will anyway. In any case, whether or not we have free will, we may soon face new choices about the ways in which we are willing to influence behavior for the better.

'If you met me, you'd never know I was mentally ill. In fact, I've gone through most of my adult life without anyone ever knowing - except when I've had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my résumé, my education, my accomplishments, reduces me to a diagnosis. I was surprised when, after one of these run-ins, my psychopharmacologist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medical care than "normal" people. Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions "a hidden human rights emergency." If you met me, you'd never know I was mentally ill. In fact, I've gone through most of my adult life without anyone ever knowing - except when I've had to reveal it to a doctor. And that revelation changes everything. It wipes clean the rest of my résumé, my education, my accomplishments, reduces me to a diagnosis. I was surprised when, after one of these run-ins, my psychopharmacologist said this sort of behavior was all too common. At least 14 studies have shown that patients with a serious mental illness receive worse medical care than "normal" people. Last year the World Health Organization called the stigma and discrimination endured by people with mental health conditions "a hidden human rights emergency." I never knew it until I started poking around, but this particular kind of discriminatory doctoring has a name. It's called "diagnostic overshadowing." According to a review of studies done by the Institute of Psychiatry at King's College, London, it happens a lot. As a result, people with a serious mental illness - including bipolar disorder, major depression, schizophrenia and schizoaffective disorder - end up with wrong diagnoses and are under-treated. That is a problem, because if yo

The Affordable Care Act's updated versions of HMOs are based on flawed assumptions about doctor and patient behavior.

Even when the system works as it's supposed to, and palliative care specialists arrive like the cavalry to provide comfort care, to stop fruitless and painful interventions and to support what patients want, their own colleagues may brand them murderers. It takes strong doctors to stand up to that kind of verbal abuse, to explain that courts and ethics committees have approved care that's intended to reduce suffering, to point out that the patient's own wishes are paramount. Perhaps they have to be stronger than we know. "The culture is changing," Dr. Matlock told me. "But it's not changed yet."

From: Keating N, et al "Physician factors associated with discussions about end-of-life care" Cancer 2010; DOI: 10.1002/cncr.24761.