Bioethics Forum Essay

What is an Ounce of Prevention Really Worth?

Is there an ethical case to be made for questioning the homespun wisdom, “An ounce of prevention is worth a pound of cure?” An argument along those lines caught a lot of attention when it was made in the Hastings Center Report 35 years ago by philosopher Benjamin Freedman. Now, on the 15thanniversary of Freedman’s untimely death at age 45, we commemorate his life and reflect on why his argument in that article is controversial to this day.

Freedman’s April 1977 article, “The Case for Medical Care, Inefficient or Not,” appeared under the heading, “The Ethical Costs of Preventive Medicine.”  His thesis was bracing:  there is a good moral case for our society’s apparent priority of treatment over prevention.  His thesis and argument challenged the confidence in prevention and public health that had emerged from the gigantic gains from sanitation and vaccination in the previous century and a half.

Were Freedman to write today, his thesis would be equally noteworthy.  We rely on screening tests (“secondary prevention”) to reduce the ravages of serious diseases by catching them early; proposals to limit such tests in light of evidence of their relative futility can bring legions of their defenders out of the woodwork. And the 2010 U.S. health care reform act exempts preventive measures from patient cost-sharing on the basis of the “ounce of prevention” wisdom, along with predictions of medical cost saving.  We may not live by prevention’s admonition, but we are enamored of it.

At the time of Freedman’s publication, one of us (Faust) was in his first year of preventive medicine residency.  The other (Menzel) was a yet-to-be-tenured young philosophy professor.  Freedman’s article sat both of us up in our chairs.  Faust started a rebuttal of Freedman’s headline conclusion (“It Is Better to Save Lives than to Preserve Health”), but the press of residency training led him to put it on the back burner.  Unaware of Faust’s interest, Menzel took up Freedman’s challenge a few years later in Medical Costs, Moral Choices, rejecting Freedman’s argument but articulating other reasons for partially agreeing with his conclusion.

More than two decades later, in 2004, we discovered a common interest in the question when we offered a workshop in the ethics of preventive medicine for the American College of Preventive Medicine. We found ourselves on the same page: Freedman’s conclusion was too strong for the reasons offered. Now others, too, were making similarly strong statements that provoked our suspicions and pointed toward a double standard: less evidence was needed to justify treatment than prevention. For example, Fiona Godlee, the editor of the British Medical Journal, stated in an article in April 2005 entitled, “Preventive Medicine Makes us Miserable”: “Because it is acted on healthy people, preventive medicine needs even stronger supporting evidence on benefits and harms than therapeutic intervention. . . .  Prevention may not be better than cure.”

Philosophy professor Heidi Malm claimed in theAmerican Philosophical Association Newsletter in 2002 that:

“Treatment must be supported by [only] a preponderance of the available evidence [whereas prevention requires]clear and convincing evidence or, even stronger, evidence showing it to be beyond a reasonable doubt that the recommended procedure will be good for the patient, all things considered.”

By 2010 Freedman’s provocative article was encouraging us to take a closer look at this question from a health policy perspective, asking scholars in health economics, preventive medicine, public health, law, and philosophical and theological ethics to articulate what they knew of the empirical background, causes, legal traditions, religious history, and philosophical questions that would increase our understanding of a reasonable normative approach to the question. There were some surprising findings:

  1. While most scholars in prevention have claimed that the U.S. spends 3 percent of the health care dollar on prevention, the actual number is closer to 8 percent. This may still not be an optimal percentage but is considerably greater than previously believed.
  2. While it is a common mantra that prevention is cost-saving, surprisingly few prevention interventions, especially clinical preventions, are. If we lower our standard from saving costs to being just comparatively cost-effective, prevention may still not fare much better generally than treatment.  Preventive actions that are not cost-effective may be as common as medical treatments that are not cost-effective. While the better comparison is the cost-effectiveness of like interventions (statins to prevent heart disease with bypass surgery to treat it), it is clear that prevention advocated aggressively over whole populations can be as costly and as even wasteful as treatment.
  3. One big disadvantage for prevention, however, is the way cost-effectiveness studies are structured, especially related to discounting. Treatment results are usually observed relatively quickly following intervention. Prevention results often cannot be observed for many years. Discounting health benefits back to what economists call their “present value” implies that one person’s life 10 years from now is worth less than a similar person’s life today. Yet ethically this makes little sense. Does ethical critique, therefore, demand a fundamental change in the standard practice of cost-effectiveness analysis?
  4. Philosopher Norman Daniels notes that prevention is related to areas outside of medical care as well: “Fair distributions of . . . basic liberties, education, job opportunities, income, and wealth – have a significant impact on health, protecting it and distributing it more fairly.”  His conclusion is that justice requires “a robust social obligation to protect and promote health “above and beyond even preventive medicine and public health, though without neglecting curative interventions.”
  5. We may have a hard time prioritizing prevention over treatment because the suffering that calls for treatment is exhibited right in front of us, whereas we need to imagine what the suffering will be if we do not prevent disease. We are influenced psychologically by this so-called “affect heuristic”: immediate vivid information has the greatest impact on our judgments and actions.
  6. Ethical judgments are not made in sealed chambers of rationality – traditions inform our reasoning. Western religions – Judaism and Christianity in their various forms – influence our ethical norms. These religions have often been heavily biased toward helping the currently needy over the future needy; taking care of indigent and suffering individuals is humane, urgent, and compassionate, and that favors treatment more than prevention. However, one branch of Christianity, Seventh Day Adventism, since its origins in the mid-19th century, has steadfastly emphasized prevention as an equal if not superior partner.

Recent and current controversies about prevention push us to extend, refine, and re-evaluate these findings. For example, recommendations for changes in preventive services can certainly trigger some of the same affect heuristic that treatments typically do. When the U.S. Preventive Services Task Force recommended reduced frequency of screening for breast cancer, for example, the political heat taken by the Task Force was intense, though it based its recommendation on the most recent evidence of screening’s effectiveness. Even though additional interventions may be of little if any value, the judgments of what is “right” for screening that were adamantly expressed by breast cancer advocacy groups reflected an ability to imagine vividly a preventive measure’s effect that would not emerge until well into the future.

Fifteen years after his death Benjamin Freedman continues to provoke ongoing inquiry.

Halley Faust is President-Elect of the American College of Preventive Medicine and Clinical Associate Professor in the Department of Family and Community Medicine at the University of New Mexico. Paul Menzel is Professor Emeritus of Philosophy at Pacific Lutheran University, Tacoma, Wa. The authors are co-editors of Prevention vs. Treatment:  What’s the Right Balance? (Oxford University Press, 2012).

Posted by Susan Gilbert at 04/02/2012 09:45:04 AM |

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