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47,000 Women Could Die As a Result of the New Mammogram Guidelines

Cost-benefit analysis can kill. Scaling back on mammograms, as a government task force suggested, could result in 47,000 unnecessary deaths.

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Aronowitz also claims the figures show that mammograms haven’t helped prevent breast cancer. He observes that the rate of 28 breast cancer deaths per 100,000 people has not changed substantially since the 1950s, despite more mammography and better treatments. But that could mean, and probably does mean, that there has been an increase in breast cancer offset by earlier detection and better treatment, saving tens of thousands of lives, but not affecting the overall rate. But he did not consider the possibility that the occurrence of breast cancer might have increased, while the rate of deaths did not change because of earlier detection due to mammograms.

I suspect that the real harm intended is economic harm – the costs of the “unnecessary” mammograms and biopsies. But the task force gives no figures weighing the economic costs versus the human cost of the deaths of 47,000 women. Now, in cost-benefit analysis, a commonly cited figure for the value of an American life is $6.5 million. Forty-seven thousand times 6.5 million is $305,500,000,000. That is, 305 billion 500 million dollars. Of course, that would be spread over the next 40 years, but it’s not clear that such a cost-benefit analysis would make this less than the cost of mammograms and biopsies, all moral issues and human costs aside. Unfortunately, the Preventive Services Task Force doesn’t do the calculation, so my figures may be off. The exact figures are not the point. The point is to go beyond rates to numbers.

In the present debate over health care, economics has become the main issue, but the Preventive Services Task Force hides it by framing. Cost-benefit analysis has been reframed as “risk-benefit analysis,” as if the task force were not concerned with “cost” to insurance companies and taxpayers, but rather with “risk” to women. But risk-benefit analysis is just cost-benefit analysis, which in turn is what corporations use to maximize profit in the short term. Both cost-benefit analysis and the Preventive Services Task Force were introduced as government institutions by the Reagan administration. They were right-wing moves – part of the strategy to privatize government.

As the Obama administration shifted the health care debate from morality to economics, cost-benefit analysis entered in the form of “evidence-based medicine," in which the “evidence” comes from statistics. This is seen as a major way to reduce the cost of health care. This is where risk-benefit analysis is cost-benefit analysis publicly and proudly discussed.

Is such an application of cost-benefit analysis always immoral? Hardly. It can be very useful. But it has to be looked at carefully, as the mammogram example shows. In the mammogram example, low probability events can have major effects!

When is a case of evidence-based medicine that uses cost-benefit analysis an instance of low probability events that can have major effects, effects serious enough to far outweigh the cost-benefit analysis? This is a serious and difficult question.

It is also a question of concern in the Obama White House. There are three high-powered experts in the administration who are committed to such questions. One is Ezekiel Emanuel, Rahm Emanuel’s brother, who is perhaps the best-known advocate of evidence-based medicine. He is an adviser to the second expert, Budget Director Peter Orszag, who sees medicine as an economic problem. The third is Cass Sunstein, Obama’s Administrator of the White House Office of Information and Regulatory Affairs, who is also known as the cost-benefit czar. Sunstein is known for specializing in low-probability events that have major effects. Political observers should watch how such issues are handled by the administration as they arise.

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