The attraction arises from the general nature of his characterization of choice. This characterization, which seems generally right to me, has nothing to do with mammograms or even health care services. It is instead a sort of microeconomic account of choice which posits that the right option for a given individual faced with a given decision is the one that maximizes the individual’s welfare. The decision might be to have a mammogram or purchase a TV. Without knowing the individual’s values, risk tolerance, etc., no recommendation can be made. And, because individual’s welfare functions vary, people who seem similar on the basis of objective conditions may properly and reasonably prefer different options.

So far, so good.

The problem arises, I believe, because there is no identified reason to give priority to the patient’s preferred option. In normal microeconomic theory, the person making the decision bears all the costs and enjoys all the benefits of each available option. Here, however, significant costs are borne by third parties, usually taxpayers or other persons in the same insurance pool. These costs include the bulk of the direct costs of the procedure and the bulk of the indirect costs, such as the costs of treating women who are diagnosed as false positives. The ability to lay costs off on third parties both skews the individual choice (by making procedures more welfare enhancing than they otherwise would be) and creates an obvious reason for limiting individual’s freedom of choice (because the third parties have a legitimate interest in not paying for services when expected costs exceed expected gains).

For every life a mammogram saves, ten more women are subjected to treatments for cancers that would have never become life threatening. Of course, each of these is counted as a life “saved,” even though it was never in danger.

More info here, in the LA Times.
http://bit.ly/1GINyH

Thanks for an intriguing take on this issue; it’s really nice to hear some nuance.

I trust it is not too vulgar of me to characterize your position as a type of moral relativism, wherein the emergence of a ‘right answer’ is dependent upon the personal values of the individuals involved. Regarding this, I am interested in your endorsement of the ‘new medicine’, which you characterise as a phenomenon of the postmodern era. I wonder if you think it is fair to suggest that you have developed a normative ethical stance (it is right and good that morality is dependent upon personal values) out of what was originally a descriptive ethical sketch, namely J-F Lyotard’s ‘Postmodern Condition’ in which he describes the ways in which late-twentieth-century western society operates *as though* morality (or truth) were dependent upon personal preferences and values?

I should add that I consider myself a moral relativist, but find myself somewhat concerned by the way in which you seem rather unironically to be claiming that moral relativism is the ‘right’ answer here.

Again, thankyou for your splendid blogpost.

Dan O’Connor

The fascinating thing from the point of view of the “new medicine” is that even with rough agreement on these facts, neither the proponents nor the opponents of routine screening can make a definitive case for their position. The correct answer for a woman contemplating whether to be screened cannot be derived directly from the fact that there is a small chance a death-causing cancer will be caught. It cannot be based on the fact that the screening will produce lots of useless, anxiety-provoking tests. Both sides agree on these factual matters. The correct answer has to wait until a woman imposes her own unique values on these facts. If you are really worried about a small chance of a preventable death and not too worried about needlessly causing anxiety, you should be screened. If you find the anxiety really troubling, don’t want the trauma of the false-positives, and are worried about the costs (to yourself or your insurer), then you should not be screened. Both answers make sense even if we assume the same facts. As long as the values of the women making the choices are different, they will rationally make different choices. No amount of medical expertise about the facts of cancer diagnosis and of the psychological reactions to tests can tell women what is right for them. Only their own values provide the answer.

Robert Veatch

I fully agree that “new medicine” is the way forward, that each person should make medical decisions in the context of his or her own beliefs and values. What most intrigues me in your discussion, though, is your supposition that “decisions such as those addressed by the mammography task force and its critics cannot be derived from the facts alone.”

The problem, as I see it, is that the facts, in themselves, aren’t as clear as the press has depicted. What if we – scientists, physicians, even economists – don’t really know how effective is breast cancer screening in 2009? Maybe mammography really is effective, and the study authors failed, simply, to demonstrate that.

To make informed decisions, the public needs information that’s both interpretable and true.

Elaine Schattner