Bioethics Discussion Blog: You Failed to Screen for Cancer? You Got Cancer? There's a Penalty for That





Wednesday, November 15, 2006

You Failed to Screen for Cancer? You Got Cancer? There's a Penalty for That

An article in the British Medical Journal for October 28, 2006 relates that the German government as part of a package of health reform legislation, yet to be passed, has a law that would penalize cancer patients who did not undergo screening for the cancer before the cancer was diagnosed. Patients with chronic illness currently pay up to a 1% maximum of their gross income for their health care, whereas the cancer patients who did not screen would have to pay up to a 2% maximum.. The screening tests advised for adult Germans include fecal occult blood testing and colonoscopy for colon cancer, cervical smear tests for cervical cancer and breast exams and mammography for breast cancer detection in women and rectal exams for prostate cancer. My reading of the age to begin testing and the frequency of the testing appears similar to criteria in the United States. But the ethical issue is whether patients who are suffering the emotional and physical pains of cancer should have another burden, a penalty of not having been screened for their disease. The ethical principles involved here, in my opinion, would be that of justice vs beneficence. Presumably, the rationale for this law is to have the patients be responsible, and not society, for the presumed added costs for treatments which is felt they brought on themselves because of their failure to be screened. The other rationale would be, through this penalty, to encourage people to participate in cancer screening for their own personal benefit. Both of these rationales would have to be based on the assumption that all cancer screenings would be sensitive and specific enough to detect the cancer in every patient who was later to become symptomatic of the cancer. How about penalizing patients with other diseases which are related to personal poor health habits: alcohol, tobacco, illicit drugs, overeating and ??? riding motorcycles. What is your take on this issue? ..Maurice.


At Thursday, November 16, 2006 8:33:00 AM, Anonymous Anonymous said...

Interesting article. I somewhat agree, only if it makes people more aware of the available cancer screening tests. A Penalty of 1% of income, it is not anough of a detrrent. On the other side of the coin, I am prudent to get as many tests as I can as cancer runs in the family. Now just found out that I have bladder cancer - that does NOT run in the family gene pool. My Family doctor is surprised, mentioned yes I know the tests came back positive 2 years ago but I always wait for three tests (urine tests). What penalty shall I put on this Medical Doctor to let me walk around like that. The whole medical debate cuts two ways, there are also wrong test results. Again, I agree with countries when they make a lot of the cancer tests available to their population. To then blame the victim is unethical.

At Thursday, November 16, 2006 11:55:00 AM, Anonymous Diora said...

The argument for penalizing people who don't participate in screening assumes that screening tests are cost-effective and "save taxpayers money". Yet, this is hardly a given. If you consider the cost of mammograms, for example, and factor in the cost of evaluating false positives as well as the increase in people actually diagnosed with the desease (because of overdiagnosis), the cost is going to be several orders of magnitude greater than the savings. I challenge anybody to try to show cost savings even using these fairly optimistic numbers. But USPSTF estimate of NNS is more than twice less optimistic (over 1200), while the recent Cochrane review referenced in one of the rapid responses to the BMJ article mentioned here is 2000. The same review also estimated that for each person who benefits, there'll be 10 people who are treated unnecessarily -- so it seems German politicians flanked their math.

Another test included in German plan is rectal exams for prostate cancer. This one has never even been shown to have any benefit at all. The history of screening infants for neuroblastoma in Japan clearly shows the danger of screening before there is evidence of benefit.

Another thing. Cancer screening is not the same as bad personal habits such smoking or alcohol. Not that I am advocating penalizing people for this - there is still this little issue of personal freedom (and what about elite gymnasts, figure skaters, etc. or just plain driving) - but still there is no harm in stopping smoking, only benefit. At the same time cancer screening has serious risks. There are false positives that lead to more invasive tests which in themselves have risks as well as anxiety (not really good for you if you have a family history of heart desease). More importantly, many types of screening result in overdiagnosis. So if you get screened (with tests that are actually proven to save lives) there is a small chance that your life will be saved, but at least in some cases there is a higher risk of becoming a cancer patient with all these entails. Another more subtle risk is finding out of an incurable cancer earlier and experiencing longer period of morbidity without change in the end result. The choice is often less than clear and while I agree the tests should be made available to those who desire them, the decision of whether or not to have tests should be a personal choice.

This virtual mentor commentary on informed refusal mentiones the ethical issues involved and the respect for personal choice. It also mentione that today screening is becoming a religion with the accompaning desire to convert everyone to the cause. This article clearly explains the risks of cancer screening.

At Thursday, November 16, 2006 4:18:00 PM, Anonymous Anonymous said...

Some screenings, such as colonoscopy, are invasive. Surely it is the patient's right to choose? I get very uneasy when screening - or any kind of intervention - gets shoved down people's throats. It's not the government's or anyone else's decision to make on our behalf.

Screening and prevention tend to be conflated, and they are *not* the same thing. Failure to be screened does not cause cancer; the purpose of screening is to detect any cancer that might already be there. Screening is not foolproof, nor does it guarantee a good outcome.

Also there are lots of cancers for which there is no effective screening - leukemia, for instance, or pancreatic cancer. Why are we picking on certain diseases and not others?

At Thursday, November 16, 2006 6:34:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is a little mathematical formula devised by physician-ethicist Steve Miles which should supplement the proposed German law. Did you notice almost anything can be supported by a mathematical formula? ..Maurice.

Health care bill = Health care cost x Personal Responsibility Multiplier (PRM)

PRM = ((BMI/20) x 3PY-10 x .4 MPDY x .2 JMDY x 1.5 (EODY-1.5)x XS x 2XXS + 1.2 UMPEBF)/1.2 AHWY x SEC40+-CD



AHWY = Aerobic hours per week years

SEC40+-DD Socioeconomic Class (I-V) after 40 if patient does not have a Major Disabling Disease

(SEC before 30 is not included; its not your fault).

EODY = Ethanol ounces per day years (adjusted for beneficial effects of 1.5 oz per day)


MPDY = diet of meat in pound day years.


PY = Pack years of smoking

XS = Hazardous sports (only scored at time of injury, includes skiing and not wearing seatbelt). If present score as 1.

XXS = Xtreme sports (if present score as 2)

UMPEBF = Unprotected multiple partner exchange body fluids

JMDY = being a jerk to your MD and his/her advice years

Notes: DNA is not included; it is not your fault.

This formula eleaborates on the new German model in including penalties for not seek health care screening (JMDY) but it goes on to properly penalize heavy schnitzel (MPDY) and beer ingestion (EODY).

Please do not write me for permission to use this. I do not believe in intellectual property rights and this hardly constitutes intellectual property.

At Thursday, November 16, 2006 7:00:00 PM, Anonymous Diora said...

Wow, this formula is so cool! ROFLLMAO

May not work for German government though because while they are very keen on screening, they don't want to do anything about smoking. Germans smoke a lot and there are hardly any regulations. They smoke at workplace (unless someone objects, but unless you are really secure in your position you are reluctant to do it), they smoke in restaurants, they smoke in all public places. Their trains have smoking and non-smoking areas, but if you happen to be in a non-smoking area but near the smoking one - tough. From personal experience, just came from a trip there. Their restaurant association only plans to install smoking and non-smoking areas by 2008 and its only in their member restaurants.

Now compare the risks of smoking with the potential benefit of screening... Somebody in German government really cannot do math.

At Friday, November 17, 2006 6:17:00 AM, Anonymous bob koepp said...

It's probably true that most government officials, and not just the German variety, are math-challenged. But this isn't about math, or even about balancing costs and benefits. It's about self-righteous wannabe tyrants whose meddling causes more human misery than the vices in question.

At Friday, November 17, 2006 6:01:00 PM, Anonymous Moof said...

Dr. Bernstein, I think that people should make their own decisions about testing, although I'd like to believe that the decisions they make would be "informed decisions."

As far as the government meddling in people's affairs, I have some very strong beliefs ... and I don't like to see the government involved in medicine in any way. I also don't like to see them paying for the indigent - because that's an open invitation for them to pull exactly this sort of meddling. Do I have any better immediate solutions? No ... although I have some rather radical ideas which would require the restructuring of both healthcare and the government!

Aren't you glad I'm not in politics! ;o)

At Monday, November 20, 2006 7:43:00 AM, Blogger Maurice Bernstein, M.D. said...

Here is a response to the German government proposal and to Diora's comments by Kevin Powell, a physician-ethicist. ..Maurice.

If enacted in the United States, the German proposed penalty of an extra 1% of gross income amounts to an almost trivial $400 at the median income, about the price of a speeding ticket in a highway work zone. That certainly does not cover the extra costs of cancer care (justice). As such, it merely represents a realistic penalty for what society deems misbehavior (personal responsibility, a term missing from the Georgetown Mantra but recognized in many other countries as part of medical ethics.) The threat of fine or even just the persuasion of having a law requiring it may be enough to get many procrastinators to be screened (beneficence).

If a speeder causes an accident, even one in which their car is damaged and in which they themselves have been injured, a citation is issued and a fine imposed. A drunk driver who kills another person may feel great emotional remorse and have some physical injuries himself, but those traumas and the virtue of compassion still do NOT prevent society from ethically adding "another burden" in form a fine, license suspension, and, too rarely, even jail time. Anon#1 misuses the concept “blaming the victim,” which usually refers to victims of crimes. Suffering does not equate to being a victim and does not absolve culpability for actions.

There is no need for the screening test to be 100% sensitive if the penalty is based on having been screened rather than the outcome.

We do penalize other behaviors with sin taxes on alcohol and tobacco. The feds would tax condoms as well except that would just discourage condom use rather than sex itself. Caffeine and nicotine are legal, cannabis and meth are not. Society can debate the science of whether or not marijuana should be legalized, but that debate is a social and political process, not prima facie ethics. Once decided, government has authority to enforce law.

Obviously, there are many other irresponsible behaviors we do not penalize, for various reasons. Listing those behaviors in an absurd fashion implies that we cannot therefore regulate any of them. That argument is an entertaining sound bite but it promotes faulty critical thinking. The logical argument of reductio ad absurdum does not apply in this situation. For example, we regulate many activities while driving. These include speed, use of turn signals, functioning brakes, adequate tire tread, blood alcohol level, and now even cell phones. We don't have laws about applying makeup while driving, eating while driving, screaming toddlers in the backseat, or looking at your passenger during a conversation and many other distractions. Only in extreme cases, and then usually only after a collision, might these behaviors be penalized under the rubric of negligent or reckless driving. That lack of comprehensive enforcement doesn't make it ethical to drive distracted nor does it make it unethical to regulate speeding.

The legal system may apply a fairness rule, such that the selection of behaviors we choose to regulate and penalize must not be discriminatory and the penalties imposed must not be excessive and must be concordant with penalties imposed for similar misbehavior. But law does not require us to either regulate all or none.

Diora questions the science behind colon cancer screening. I won’t debate those arguments as I am partial to some of them. At some point, however, as a major payer of health care costs, the government has a stakeholder interest. That gives it moral authority to weigh the science and make a policy decision. Not everyone will agree with the wisdom or soundness of the verdict, but that is true of any law. As a libertarian, I advocate the government limiting its scope. But I don’t find valid arguments for labeling the German proposal unethical. The citizen still has the choice to refuse testing and risks paying only a pittance if that choice was wrong. As a token effort at promoting personal responsibility, in the long run such a law reinforces basic liberties.

Kevin Powell MD PhD

At Monday, November 20, 2006 10:46:00 AM, Anonymous Diora said...

First of all I'd like to point out that Dr Powell misquoted me. My post has never even mentioned colon screening. The screening I did mention was digital examination for prostate cancer. Shall I remind Dr. Powell, that USPSTF hasn't found any evidence of benefit of prostate screening yet it is one of the tests that German government includes in its list - it illustrates government's ability to truly make evidence-based decisions; it also shows the danger of such plans and why one cannot compare screening with traffic signs or highway speed limits.

Second, I strongly object to the labelling of the refusal to participate in screening as "irresponsible behavior". Screening has benefits as well as risks. Is a small chance of having one's life prolonged worth a higher chance of being diagnosed with cancer and suffering from serious, maybe life-threatening side effects from unnecessary treatment? Is it worth all the false positives, and biopsies and the accompanying anxiety? Shall the individual be allowed to make his decision based on careful evaluation of beneefits and risks as they apply to his personal preferences or based on government penalty?

Is not participating in prostate screening the benefit of which is debatable but that has definite risks "irresponsible behavior" on par with reckless driving? Should men base their decision of whether or not to take the test whose value is debatable but that can result in unnecessary treatment that can cause incontinence and impotence not on evidence and their preferences but on how much money they'll have to pay if they get sick? If a woman decides that 1/1200 chance of having her life prolonged (I am using USPSTF estimate for 50+ women) is not worth several times higher chance of being converted into a cancer patient unnecessarily, is she irresponsible much like somebody who runs the red light? It is irrelevant of whether the penalty is big or small, just the presence of the penalty violates the principle of informed consent, IMHO. So how can Dr Powell possibly compare a medical intervention with traffic rules?

And before he brings up infectious deseases, cancer screening is not the same as infectious desease prevention since people with chronic deseases don't infect others. The refusal to participate in screening doesn't impact other people's life and health. There is no clear case for cost savings associated with cancer screening (or any chronic desease prevention) either: while screening tests that prevent cancer like pap smears or colon may be cost-saving, screening that simply detects cancer early is not likely to be. And even if somebody's life is prolonged by screening and this person gets diabetes later or some degenerative desease later and dies from something else, does this person saves money or uses more money?

And what about preventive drugs. How about penalties for not taking statins or blood pressure medication or osteoporosis prevention drugs? Hey, maybe in pre-WHI era it was irresponsible for a woman not to take HRT?

In our culture screening is turned from science into religion and everybody who isn't a convert is "irresponsible". It scares me to death.

At Monday, November 20, 2006 12:32:00 PM, Anonymous Diora said...

One other thing. Dr Powell is talking about the extra costs of cancer care (justice) that "the irresponsible behavior" of refusers cost. Because his whole argument that the refusers are irresponsible is based on the cost, I'd love some evidence how these irresponsible people use up healthcare dollars. Notice, that I am not talking about cost-effectiveness that is measured in $$$ spent on one year of life prolonged, I am talking about actual savings.

How about using mammograms as an example? (shall I ask for prostate as well? You can use some evidence of benefit that USPSTF overlooked). You can do your own calculations or provide references provided that both your calculation and references factor in false positives, additional number of people diagnosed and the fact that screening only makes a difference in a small percentage of cases and that mere early detection does not necessarily make a difference in final outcome. Factoring longer period of treatment for those whose desease is not helped by screening would be nice as well. Of course, it would really be nice if you could then compare the person who ends up costing more money and dies younger to somebody whose desease is really helped by screening and who lives 20 years more only to have a relapse or to get Alzheimer later in life.

Dr Powell, you call people who decide that the benefits of screening is not worth the risks "irresponsible"; you also consider screening not a personal choice one shall make based on careful consideration of benefits and risks but a "responsible behavior". Prove it.

I feel very strongly about the subject because even if the penalty German government proposes is small, it sets up a precendent. Who is to prevent an insurance company or a corporation in the US to deny care to people because they hadn't been screened or refused to take preventive drugs?

At Monday, November 20, 2006 5:03:00 PM, Blogger Maurice Bernstein, M.D. said...

Diora, I notified Kevin about your postings and I look forward toward a rebuttal from him, if he desires to do so. I think that the issue that you and Kevin are debating is really quite important from an ethical/philosophical view but also from a pragmatic/political view. I think that this debate is really what I had wanted as the function of my Bioethics Discussion Blog. I hope it provides my visitors from around the world who are not ethicists but are affected by laws, political views and diseases a chance to see different sides of ethical issues and become educated. ..Maurice.

At Tuesday, November 21, 2006 8:59:00 PM, Blogger Maurice Bernstein, M.D. said...

Dr. Kevin Powell requested that I post his rebuttal to some of Diora's concerns. To me, it does seem that the views of both Kevin and Diora are reasonable and there are seemingly even perhaps shared views. ..Maurice.

I have seen some preventive medicine which is very cost-effective (some vaccines save $10 for every dollar spent) but most preventive medicine is cost-effective only when treatment of the disease is made cost-prohibitive through expensive, poorly effective therapies that are administered without respect to value. The exceptions are relatively few. Clean water, good diet, seat belts, and no substance abuse, especially driving intoxicated. Exercise is borderline helpful, yielding about one hour of extra life for each hour spent exercising.

Talking cost-effectiveness is complex because in most cases letting people die is the cheapest strategy. Smoking is clearly bad for your health, but cheaper for society because of savings in social security and pensions. Using medicine to improve and prolong life requires a cost-benefit approach. Some medical care yields extra years of life for less than $1000 per year added, such as malaria prevention programs. Bill Gates is supporting those. Yea, Bill. A few of the new biotech drugs cost as much as $400,000/yr of therapy. Cholesterol lowering statins look midrange, adding a year of life for something around $20,000 give or take a factor of four. Of course, that extra year of life also has costs for room, board, and other medical care. That implies that many minimum wage Americans, if they were paying for things out of pocket, might be smarter to not buy the drug and enjoy retiring a couple years earlier or working less hours each week.

So this is rather complex for a blog, but let me refute some assertions Diora made:

…it also shows the danger of such plans and why one cannot compare screening with traffic signs or highway speed limits.

Certainly government makes lots of poor decisions. I can list other health programs among them. But has the free market or unaccountable individual choice proven to be better in the long run? Making regulations is what public policy makers do, whether in the DOT or HHS.

The refusal to participate in screening doesn't impact other people's life and health.

Ah, but with health care costs at 17% of the U.S. GDP and most of it paid with communal resources, it does impact other people. What is novel about the German proposal is that the proposal makes that externality more explicit with a token payment.

In our culture screening is turned from science into religion

I agree. And as a libertarian, I think government should be cautious about enforcing its religion.

Dr Powell, you call people who decide that the benefits of screening is not worth the risks "irresponsible";

No, the German proposal concludes that. You disagree with their scientific verdict. You may be correct in many cases of preventive health care. Under the proposal, you have the right to disagree and the right to refuse testing. If you exercise that option, there are consequences.

just the presence of the penalty violates the principle of informed consent

No it doesn’t. Informed consent does not imply you get to make choices without accepting financial consequences. Freedom of choice is not free. That is the very definition of being responsible.

Who is to prevent an insurance company or a corporation in the US to deny care to people because they hadn't been screened

The problem with slippery slope arguments like this is that they do not advance a meaningful dialogue. If you distort things to one extreme, it usually conjures up a bad result. However, that bad observation does not allow you to logically conclude that we must therefore adopt the other extreme. For example, cooking frozen pizza in a 900 F kiln makes bad pizza. But that doesn’t mean I should try to cook it in the refrigerator. Once in the oven, what is to prevent someone from setting the thermostat to broil? Intelligence.

At Thursday, November 23, 2006 10:58:00 AM, Anonymous Diora said...

It does seem that we have some shared views. I think the main difference is that I view screening and any medical intervention, especially invasive interventions that screening leads to given the number of false positives as fundamentally different from other laws while Dr Powell sees them as similar. I also don't see the issue as a question of "justice" vs "beneficence" but rather as that of the government's right to impose(using Hazel Thornton's words) "potentially damaging interventions on healthy individuals with financial penalties if they resist". One may argue that the government already does it with regards to infectious deseases, but the balance of benefit for others vs risk to an individual is incomparably more obvious in the latter. I believe that the evidence of benefit must be overwhelming and the risk of harm to an individual exceptionally small before the government is allowed to impose medical interventions on people. Yes, people make bad choices as well, but at least in this case there is the evidence that a bad choice of an individual hurts anybody else is lacking.

A couple of points:
Informed consent does not imply you get to make choices without accepting financial consequences
Informed consent implies providing information to patients. The German plan doesn't include the requirement to inform people of pros and cons of screening. "If you don't do it you'll have to pay more" is hardly an adequate information about risks and benefits of screening. Most people don't read scientific studies or papers in medical journals for fun; most people don't even understand the difference between absolute risk and relative risk; most people think of medical tests as risk-free. Somewhat off-topic: I've always been wondering if by failing to inform patients of the risk of overdiagnosis and by "framing" information to make the benefit appear larger, American doctors violate the principle of informed consent.

Ah, but with health care costs at 17% of the U.S. GDP and most of it paid with communal resources, it does impact other people
True, but before the government uses it as justification, they must provide proof of savings. Given the potential of an individual harm, I believe the bar of proof must be set higher than for government's laws that don't have such potential.

... However, that bad observation does not allow you to logically conclude that we must therefore adopt the other extreme.
But are my examples so extreme? For example, West Virginia "Personal Responsibility" medicaid plan proposes to severely restrict eligible residents' benefits if they don't adhere to, among other things, screenings. Many companies are now offering incentives to employees for "healthy behavior" that includes annual physicals (no evidence of benefit especially given average age of participants) and screenings. Currently these plans are voluntary and based on trust, but I am not sure taking these plans a step further is so far-fetched.

At Thursday, November 30, 2006 1:29:00 AM, Anonymous Anonymous said...

I thoroughly disagree with the German government's proposal. Many of the tests mentioned are invasive in one way or another -- one many not see a cervical smear or a rectal as particularly invasive, if one is in the medical profession, but frankly, most laypeople do. To financially penalise people for wishing to retain control over their own body, to me, is tantamount to rape.

As for colonoscopy, not only is it invasive, with sedation and biopsy, it is significantly risky. I do not believe that the government should or could be allowed to incite a financial penalty given the potential of risk in this case.

At Friday, December 01, 2006 8:19:00 PM, Blogger Maurice Bernstein, M.D. said...

My visitors to the Comment section of this thread might be interested to read in the New York Times how some states in the U.S. are working on programs to enhance those Medicaid patients who follow their physicians orders and punish those who don’t.. The article is about what is going on in West Virginia but..
“The incentive effort, the first of its kind, received quick approval last summer from the Bush administration, which is encouraging states to experiment with “personal responsibility” as a chief principle of their Medicaid programs. Idaho and Kentucky are also planning reward programs, though more modest ones, for healthful behavior.”
So what does this mean? The German plan in Appalachia? ..Maurice.

At Saturday, December 02, 2006 8:25:00 AM, Anonymous Diora said...

This is the plan I was referring to in my previous post.
I am wondering if such a plan is legal. After all, refusing a medical intervention is a right. While German plan imposes a fairly small penalty, Virginia plan severely curbs benefits of poor people for exercising their right to refuse treatment (or even not going to routine checkups). For some reason ACLU is strangely silent about it. I guess very few people read beyong the first page that speaks of missed appointments and ER overuse and omits the details like "you have to do what your doctor says or else". Also very few people are sympathetic to medicaid recipients. They don't understand that they might be next.

And here I thought I no longer live in the Soviet Union... Where are the lawyers when one needs them?

Maybe I should get a lawyer on retainer for time when my employer decides to follow Virginia's example.

At Saturday, December 02, 2006 9:18:00 AM, Blogger Maurice Bernstein, M.D. said...

Sorry, Diora, I goofed and somehow ignored your previous reference to the West Virginia Medicaid plan. I too wonder when the interference by government into each citizen's private lives will end. Or that just comes with the territory for participating as a member of society? ..Maurice.

At Saturday, December 02, 2006 6:08:00 PM, Anonymous Diora said...

No problem. I mistakenly used "Virginia" for "West Virginia". A scary thing is that many physicians, such as Kevin, from Kevin MD blog website say that "it should be universal".

At Saturday, December 02, 2006 7:55:00 PM, Blogger Maurice Bernstein, M.D. said...

An ethicist on a bioethics listserv to which I subscribe wrote the following regarding the issue of universal health care in the U.S.:"Where we should be figuring out how to provide for everyone, we get distracted by attempts to choose the deserving. Rewarding the virtuous and punishing those with bad habits makes sense only after we have committed to providing a decent minimum for everyone." Does that make sense? ..Maurice.

At Saturday, December 02, 2006 8:16:00 PM, Anonymous Diora said...

Makes sense to me - but then I am just an ignorant layperson. I'd still prefer to keep medical interventions out of both penalties and reward because of a potential of harm.

At Wednesday, December 06, 2006 8:53:00 PM, Blogger Maurice Bernstein, M.D. said...

Here is another comment on personal responsibility and economic value in medicine by Dr. Kevin Powell. He also comments specifically on the statement by the ethicist I referred to in my last posting here.


"Although the United States spends $2 trillion -- or 16 percent of the gross national product -- on health care, the investment has not paid off, the acting U.S. surgeon general told an Indiana University audience Wednesday [Nov 29]...There's something fundamentally wrong here,"

"Chronic diseases, including diabetes and heart conditions, cause seven out of 10 deaths annually and 83 percent of health-care spending in the United States, he said. Yet he said those problems can be largely eliminated with tobacco control, good nutrition, exercise and normal weight maintenance."

Lyndon Johnson shifted health care priorities with the creation of Medicare. Surgeon General Koop led health care in one direction dealing with the AIDS epidemic. Perhaps Acting Surgeon General Moritsugu will actively lead us in another direction dealing with the new obesity and ongoing nicotine and other substance abuse epidemics. Perhaps his speech last week was just the usual hyperbole about the benefits of prevention for an audience of public health advocates. I think it is a long overdue challenge to the primary role of medicine as a profitable (for health care institutions, not the public) means of rescuing people with illness. Of course, as a pediatrician, I am biased with the view that too many resources go into the last 6 months of life. That bias is probably the origin of my becoming a pediatrician rather than being the product of my choice.

The magnitude of those numbers cited by Moritsugu would argue against the assertion that "Rewarding the virtuous and punishing those with bad habits makes sense only after we have committed to providing a decent minimum for everyone."

The US health care system is doing much better at providing a decent minimum than at funding that minimum while simultaneously funding the technological boondoggle. So addressing personal responsibility and economic value in medicine will likely need to come first, not after. The 1990s offered us managed care and increased cost sharing (copays). Managed care, corporate version 1.0, proved unacceptable. Larger copays have had limited effectiveness so far and disproportionately punish the middle class. Therefore, the efforts in Germany and West Virginia to seek other avenues to directly increase personal responsibility seems to be headed in the right moral direction. The methods proposed may have their strategic flaws, but that warrants constructive criticism and some guidance from medical ethics. The condemnations of the principle of personal responsibility for health strike me as belonging to the category "Man will never fly." The engineer in me realizes it is time for ingenuity, not derision. Incorporating personal responsibility in health care delivery is a complex, overwhelming task to undertake. It may require abandoning the Georgetown Mantra and looking for a balance between autonomy and responsibility. Balances, as Aristotle pointed out, are much harder to advocate and achieve than merely idolizing one fundamentalist extreme. But that will be the task before medical ethics in 2010.

At Monday, February 09, 2009 10:18:00 PM, Anonymous Anonymous said...

This is unfair...
Cancer screening has risks as well as benefits - for some high risk patients the risk of a false positive might be acceptable to them...a low risk person may not wish to risk unpleasant and possibly harmful follow-up for a false positive.
If it's an uncommon cancer, it must be a reliable Test otherwise healthy people end up being harmed.
Also, I strongly believe it's every person's right to refuse anything unpleasant or invasive - it's up to the individual the risk they're prepared to accept...
I have refused cancer screening - after doing my reading, asking lots of questions and considering my risk profile....I decided the risks exceeded the benefits.
That is my right and I should not be penalized for that....
I really think all this cancer screening is getting out of hand - doctors bullying patients into tests and receiving financial incentives to get patients on board - it's unethical and improper....
A Dr can recommend and provide information, but that's it....

At Monday, February 09, 2009 10:36:00 PM, Anonymous Anonymous said...

What about informed consent or even consent?
What happens if I'm harmed by a false positives? Will they accept responsibility?

I've often wondered about cervical cancer screening and informed consent - women are pressured and bullied every time they see a GP (keen to pick up a cheque for the number of women they get into the program) Most women get very little information - the brochure is full of overstatements and virtually no risk information. How can you consent in the circumstances?
Also, women who want the Pill are often "required" to have the Test or the Pill is can that be justified?
Birth control and so-called optional cervical cancer screening...
Particularly, in light of the fact that the only test required for the Pill is a blood pressure check....
I read recently that Dr Angela Raffles has released some amazing statistics - 1000 women need to be screened for 35 years to save one woman from cervical cancer.
Yet the scare campaigns would have you believe it's an epidemic.
In fact, I was reading some research from the US College of Pathologists that said only 1% of women would get this cancer in an unscreened population - of that 1% - one third will have received one or more false negatives, so screening may disadvantage this group - they may be reassured by the test result and delay getting medical advice for any symptoms.
The other 0.66% will benefit from the Test.
The Test is so unreliable that Dr L Koutsky's research showed that almost 78% of women will have a colposcopy and possibly biopsies over her screening lifetime (that's two yearly screening) - annual screening the figure is 95% (from the College of Pathologists - the second figure)
So, the rest of us - the 99% stand a high chance of harm from this Test - are we asked whether we agree to that risk?
No - at the moment most Drs accept that risk on behalf of their healthy patients and that's just disgraceful - highly unethical...
I took the trouble to do my reading - no one will accept this sort of risk on my behalf - with my risk profile, my risk of this cancer is something like 0.01% - I can live with that....
It staggers me that the medical profession have been getting away with this for so long - but lots of people are making an absolute fortune from this Testing and the health of women is the last thing on their minds.
The evidence against mammograms is just as bad - read anything by Prof Michael Baum...

At Thursday, April 22, 2010 9:36:00 AM, Blogger Elizabeth said...

Because of all the false positives and false negatives and because of the low benefit of screening tests in general, I've decided to forego colonoscopy (I have no colon cancer in my family, and my diet is high in fiber); Pap smears (I had a hysterectomy years ago); and mammography (at my age, the expense of treating breast cancer would not be cost effective). If I have symptoms, if I have a positive test for blood in my stool (guaiac test), if I find a lump or other suspicious area in my breast, THEN I will have the additional testing. And other than dealing with the disease itself, I don't think I should be further penalized by the government, insurance companies or the snide comments of caretakers. I'm making educated decisions here.
I do have inoculations against communicable diseases as needed, and have routine lab tests to track effects of medications for autoimmune diseases on renal and hepatic systems. These have more immediate and testable benefits.
Just a few points from an RN PhD with many years working in the Public/Community Health arena.


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