On 2017 Jul 23, David Keller commented:

Final Comments on "The Ethics of Commercial Testing"

Organizations such as the USPSTF issue guidelines which are based on the results of large clinical trials and therefore apply on average to entire populations, but may not apply to atypical individuals. We have all seen "outliers" who suffered a heart attack despite having few or no Framingham risk factors. Tests which are not justified on a population-wide basis can yield valuable information for atypical individuals. Since risk scores are not perfect at predicting who will have an adverse outcome, individuals should be allowed to decide for themselves how much risk they are willing to take, and how much of their own money they are willing to spend to assess their risk.

Consider the Affordable Care Act's mandate of free aneurysm screening for men aged 65 to 75 who have ever smoked: a man aged 65 who quit smoking 30 years ago gets a free ultrasound, but a 64 year old man who has been smoking 2 packs per day for the past 40 years does not. This makes no clinical sense, but is a perfect example of what Charles Dickens [1] meant when he said "the law is an ass [donkey]". Clinical decisions should be left to patients and their physicians, not written into law. Furthermore, these "free" ultrasounds will cost taxpayers a lot more if ordered by physicians and performed in hospital radiology departments than if patients can self-refer to commercial test companies which offer abdominal ultrasounds for $129, with carotid and peripheral artery screens included for no additional fee. The cost of hospital-based imaging is inflated in part due to excessive regulation. Commercial imaging companies can provide ultrasound at such a low cost partly because they are not yet burdened with providing mandatory counseling sessions which their customers may not even want.

Here is the crux of our disagreement. I believe that individuals in a free society should be allowed to purchase tests such as ultrasound and genetic testing, which pose no risk of direct harm. Stigmatizing commercial vendors of such tests as unethical for not providing counseling is the first step toward laws mandating counseling, which will increase the cost of the tests. To me, that outcome would be unethical.

The above comments were posted on an Annals of Internal Medicine website on March 26, 2013, and are being posted on PubMed Commons to complete the chain of comments for readers with no access to the Annals website.

[1] Mark Twain said it too, but was quoting Charles Dickens, through the character Mr. Bumble in the novel "Oliver Twist".

On 2017 Jul 23, David Keller commented:

Final Comments on "The Ethics of Commercial Testing"

Organizations such as the USPSTF issue guidelines which are based on the results of large clinical trials and therefore apply on average to entire populations, but may not apply to atypical individuals. We have all seen "outliers" who suffered a heart attack despite having few or no Framingham risk factors. Tests which are not justified on a population-wide basis can yield valuable information for atypical individuals. Since risk scores are not perfect at predicting who will have an adverse outcome, individuals should be allowed to decide for themselves how much risk they are willing to take, and how much of their own money they are willing to spend to assess their risk.

Consider the Affordable Care Act's mandate of free aneurysm screening for men aged 65 to 75 who have ever smoked: a man aged 65 who quit smoking 30 years ago gets a free ultrasound, but a 64 year old man who has been smoking 2 packs per day for the past 40 years does not. This makes no clinical sense, but is a perfect example of what Charles Dickens [1] meant when he said "the law is an ass [donkey]". Clinical decisions should be left to patients and their physicians, not written into law. Furthermore, these "free" ultrasounds will cost taxpayers a lot more if ordered by physicians and performed in hospital radiology departments than if patients can self-refer to commercial test companies which offer abdominal ultrasounds for $129, with carotid and peripheral artery screens included for no additional fee. The cost of hospital-based imaging is inflated in part due to excessive regulation. Commercial imaging companies can provide ultrasound at such a low cost partly because they are not yet burdened with providing mandatory counseling sessions which their customers may not even want.

Here is the crux of our disagreement. I believe that individuals in a free society should be allowed to purchase tests such as ultrasound and genetic testing, which pose no risk of direct harm. Stigmatizing commercial vendors of such tests as unethical for not providing counseling is the first step toward laws mandating counseling, which will increase the cost of the tests. To me, that outcome would be unethical.

The above comments were posted on an Annals of Internal Medicine website on March 26, 2013, and are being posted on PubMed Commons to complete the chain of comments for readers with no access to the Annals website.

[1] Mark Twain said it too, but was quoting Charles Dickens, through the character Mr. Bumble in the novel "Oliver Twist".