Medical Ethics Unpacked: GLP-1 Allocation and Challenges of Equitable Access

In this episode of Medical Ethics Unpacked, hosts Steve Levine, MD, a psychiatrist, and Dominic Sisti, PhD, a bioethicist, are joined by special guest Johan Dellgren, BA, a research fellow at the University of Pennsylvania’s Department of Medical Ethics and Health Policy. Together, they explore the ethical and policy challenges surrounding the allocation of GLP-1 receptor agonists, a class of medications widely recognized for their effectiveness in treating diabetes and obesity.

The conversation addresses the growing demand for GLP-1 drugs such as Ozempic and Wegovy, which have shown profound health benefits but remain costly and in limited supply. Dellgren outlines the complexities of insurance coverage, highlighting disparities in access between private insurers, Medicare, and Medicaid. Some insurers cover these medications as preventive care due to their potential to reduce cardiovascular risks and long-term healthcare costs, but others hesitate due to their high price tags—often exceeding $1,300 per month.

At the core of the discussion is distributive justice: how should these scarce medications be allocated fairly? Dellgren presents a framework known as the Fair Priority Model, developed by Dr. Ezekiel Emanuel and colleagues, which balances multiple ethical principles. The model incorporates 4 key values: maximizing benefit and minimizing harm, ensuring equal moral concern for all individuals, prioritizing the most disadvantaged, and rewarding social contribution.

A key takeaway is the prioritization of GLP-1s for obesity over diabetes, an approach based on potential years of life lost (PYLL). Dellgren explains that long-term obesity significantly shortens lifespan—by as much as 10 to 15 years in some cases. Additionally, prioritizing individuals with severe obesity could help prevent the development of type 2 diabetes and other comorbidities. The model also stratifies patients by age, prioritizing younger individuals to maximize life years saved.

Sisti and Levine challenge Dellgren on objections to the PYLL metric, particularly concerns about its racial neutrality. Dellgren explains that while the model does not explicitly factor in race, it is racism-conscious, ensuring that communities disproportionately affected by obesity and diabetes—often communities of color—are fairly represented through the prioritization of those with the highest PYLL scores.

The discussion expands to the broader implications of GLP-1 access, including the current unjust distribution system, where higher-income individuals and those with comprehensive insurance disproportionately secure these medications, even in cases where clinical need is lower.

Another key ethical issue raised is patient adherence. With limited drug supply, should patients who fail to adhere to treatment lose access in favor of those more likely to benefit? Dellgren notes that some countries, such as Iceland, already incorporate adherence-based criteria into their public insurance coverage, requiring patients to meet specific weight-loss milestones to continue treatment. The conversation also touches on whether drug patents should be suspended to allow generic production and address shortages.

Throughout, Levine, Sisti, and Dellgren emphasize the ethical complexities of rationing high-impact medications and the need for policies that balance medical necessity, social equity, and cost-effectiveness.

Dellgren and colleague’s paper on GLP-1 allocation published in the New England Journal of Medicine can be accessed here.

About Hosts:

• Steve Levine, MD: Chief patient officer at Compass Pathways
• Dominic Sisti, PhD: Associate professor in the Department of Medical Ethics & Health Policy and the director of the Scattergood Program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania

Relevant disclosures for Sisti include Lykos Therapeutics and Tactogen. Relevant disclosures for include Levine include Compass Pathways.

Editor's Note:

The views and opinions expressed by the hosts and guests are their own and do not necessarily reflect those of HCPLive or MJH Life Sciences. This content is intended to encourage thoughtful discussion and does not constitute medical advice or endorsement of any particular position. Listeners are encouraged to approach these subjects with care and consult appropriate resources for further information.