Implicit in the new recommendations that Americans take fewer cancer tests is the long-overdue facing of a repugnant but unavoidable question: how much is a life worth?
The recommendations, which represent an important turn in public-health policy, emanate from the American Cancer Society, the de facto ministry of feared sickness. What they basically come down to is that, for most people, most of the standard cancer tests should be preformed less frequently than was previously suggested. The justification for this, according to ACS officials, is that, while test invariably turn up more cases, the cost of frequent testing isn't justified by the results; furthermore, for some types of cancer, though certainly not all, early detection has little or no effect on the outcome.
The acknowledgment of these grisly facts by the heretofore test-pushing ACS is no small matter. For decades the society responded to the public's fears and hopes concerning cancer by urging individuals and physicians to maintain a relentlessly high alert for signs of the disease, with frequent tests, most of them yearly, an integral part of that alert. And then, too, there were the urgings that the checkups be accompanied checks made out to the ACS.
Although there always was professional squabbling in and around the ACS concerning the medical utility of frequent testing, the impression that the organization conveyed to the public was that prudence calls for an annual checkup. Thus, a standard ACS pamphlet, originally published in 1971, asks:
"Why is a health examination every year recommended?"
Answer: "Because it is possible to diagnose cancer before symptoms have appeared, and when it is early enough to be treated and cured."
Without much early effect, this drumbeat in behalf of frequent testing was questioned by the cost-conscious wing of health policy, an economist-dominated faction, home-based in major schools of public health (rather than in cure-minded medical schools). And their skepticism on cancer testing, as well as many other venerable practices of cure-seeking medicine, eventually spread to the bill-paying Department of Health, Education and Welfare and its congressional overlords.
They kept asking questions that seemed unthinkable in a rich society whose politics had casually accepted the admirable precept that health care is a right. The questions, conceptually derived from the heartless craft of cost-effectiveness analysis, simply addressed the actual cost of obtaining a specific medical outcome. And what was found upon close accounting of vast needle-in-a-haystack screening programs was that the cost per case detected sometimes ran as high as $50,000 to $100,000.
The standard responses for a long time were that you can't put a price tag on life, that no limits can be accepted on mobilizing society's medical resources for any who need them and that every citizen -- even if he'd sensibly rather not have it -- is due the heroic goal-line medical stand accorded such long-lingering celebrities as President Tito.
These congenial, even if misguided, attitudes easily prevailed when the economy was growing and health care's increasing share of national resource created little bother. In that atmosphere, it would have been considered outrageous to invite the American people to accept less favorable odds on cancer detection. Not so today.
Our Great Moments in Medicine used to come exclusively from episodes of healing, and we fortunately can expect more of those. But increasingly, as evidenced by the cancer society's revised thinking on the advisability of frequent tests, economics will set the pace for American health care.