High Noon for Population-Wide Mammography Screening?

By Prof. Dr. med. Dr. phil. Nikola Biller-Andorno

Director, Institute of Biomedical Ethics, University of Zurich, Switzerland

Safra Network Fellow, Harvard University (13-14)

Visiting Professor, Div. Medical Ethics, Harvard Medical School (12-14)

It is amazing how much heat a report can draw that simply states what has been all over town for some time now: We do not know if mammography screening does more good than harm, we do not even know for sure if it does any good at all.

The Swiss Medical Board, an independent health technology assessment initiative that was started in 2008, stated that based on the empirical data availability the introduction of mammography screening all over Switzerland could not be recommended.

As could be expected the report drew fire. Curiously, one of the chief complaints was that it was “unethical” to upset women who might no longer know if screening was good for them or not.

This sounds just a little bit paternalistic – particularly given that we know that most women seriously overestimate the benefits of screening when making their decision, a point that my colleague Peter Juni and myself illustrate in a Perspective piece published on May 22, 2014 in the New England Journal of Medicine.

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The misconceived reverence for life

By Nikola Biller-Andorno, MD, PhD

Times and again, individuals have asked courts in the United Kingdom, Ireland and other countries for permission to have someone help them end their lives. Diane Pretty, Tony Nicklinson and, most recently, Marie Fleming are among those who suffered from a serious disease that prevented them from acting on their wish by themselves. Their requests, highly publicized and intensely debated, were all turned down.

There are concerns about the legalization of assisted suicide, such as the danger of abuse, that merit attention. One of the core arguments against physician involvement is that medicine is about saving lives, not about ending them. This argument, with its underlying notion of an unconditional reverence for life, is flawed.

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UNOS Proposes a New Kidney Allocation System

By Nikola Biller Andorno

The Kidney Transplantation Committee of the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) has put forward a proposal that would substantially revise the existing national allocation system for kidneys from deceased donors. It would also dissolve alternate local kidney allocation systems, which were put in place to study various allocation methods, some of which have been incorporated into the new proposal.

The proposal contains a number of provisions. Whereas the current allocation system is focused on the time a patient has been on the waiting list for a kidney, the new proposal suggests a tiered system: The 20% of kidneys that are ranked highest with regard to the likely duration of functioning once transplanted will be matched with the 20% of candidate recipients who are expected to have the longest time to benefit from a transplant. The logic behind this suggestion – like many others driving health policy considerations these days – is an attempt to maximize utility. Although the attempt to extract the most benefit out of a precious, scarce resource is certainly in keeping with good stewardship, the proposal raises concerns about fairness: What about patients who have a lower life expectancy due to age, disability, coexisting conditions, or socioeconomic status? Will they be deprioritized, with an increased risk of either dying before they get a transplant or of receiving a transplant that may not last for long? This would mean a departure from current policy, which focuses on waiting time, and it would also diverge from policies for other organs, such as livers, in which urgency is of primary concern and very sick patients are prioritized. On the other hand, stratifying organs for transplantation is not entirely new: in an attempt to reduce the number of discarded organs, several European countries have established so-called ‘old-to-old’ programs, which match the kidneys of donors 65 years of age or older with recipients of a similar age.

At the same time, the OPTN/UNOS proposal aims to promote equality of opportunity for the remaining 80% of potential recipients, by calculating their waiting time from the onset of end-stage kidney failure rather than from the date when they were added to the waiting list and by correcting for biological factors such as uncommon blood type or high immune-system sensitivity.

The proposal can be expected to undergo careful scrutiny by the different stakeholders. There is a period for public comment running through December 14, 2012. Have a look at http://optn.transplant.hrsa.gov/news/newsDetail.asp?id=1579 and contribute to the debate.

Introducing Nikola Biller-Andorno

We’re pleased to introduce and welcome Nikola Biller-Adorno to our blogging community as an occasional contributor.

Nikola  directs the Institute of Biomedical Ethics at the University of Zurich, Switzerland. She has been deputy editor of the Journal of Medical Ethics, and is the immediate past-president of the International Association of Bioethics. Currently, she is spending a year at Harvard and the New England Journal of Medicine as a Commonwealth Fund/Careum Foundation sponsored Harkness Fellow, exploring ethical and policy issues of health care reform.

Some of Nikola’s representative works include:

Welcome, Nikola!