One of the phrases I find myself using quite a bit on MH Blog and beyond is what I've referred to as "the unbearable oughtness of health policy." This signifies the notion that allocating scarce resources to health -- which, as I have repeatedly noted here is both distinguishable from and not reducible to health care -- is always and forever a value-laden affair. All of the descriptive analysis in the world, however critical it may be to informing moral discourse, cannot determine what is a just distribution of resources and capabilities related to health. This is of course simply an instantiation of the naturalistic fallacy; "is" never determines "ought."
Along these lines, there is an outstanding new article on NEJM's Health Policy Forum tracking a similar line in reference to the recent brouhaha over changes in mammography screening guidelines recommended by the U.S. Preventive Services Task Force. The article is entitled "Lessons from the Mammography Wars." Here is an excerpt:
In the case of any given patient, we must choose to treat or not treat, to screen or not screen. In an effort to help us make these choices, our profession is constantly trying to elucidate clear thresholds for intervention, such as the level of glycated hemoglobin or low-density lipoprotein cholesterol, age, or standard time intervals. What we often do not remember is that these thresholds — for example, an age of 40 versus 50 years or annual versus biennial routine mammography — are to some degree subjective and arbitrary. After all, scientific evidence can only help us describe the continuum of benefit versus harm. The assessment of whether the benefit is great enough to warrant the risk of harm — i.e., the decision of where the threshold for intervention should lie — is necessarily a value judgment. When either side in the mammography wars claims that the evidence suggests that women should or should not undergo routine mammography starting at the age of 40 years, they are deceiving themselves and the public about what the evidence can tell us. They are really just making different value judgments about where to set the threshold.
This is part of the reason the idea that evidence ever "speaks for itself" is nothing but a convenient fiction, although the fact that the fiction is so prominent a marker of epistemic validity is hugely significant in its own right (I have some work on the relation of this point to the history of objectivity in the West).
To their credit, the authors discuss in some detail the influence of money and conflicts of interest in the production of evidence and its interpretation:
But what if those experts are basing their recommendations on more than the interest of patients alone? In any other industry, we accept the idea as natural that those providing a service or product hold their own and their shareholders’ interests as a primary objective. Why have we failed to acknowledge that the same phenomenon occurs in health care? Although it is true that individual medical providers care deeply about their patients, the guild of health care professionals — including their specialty societies — has a primary responsibility to promote its members’ interests. Now, self-interest is not in itself a bad thing; indeed, it is a force for productivity and efficiency in a well-functioning market. But it is a fool’s dream to expect the guild of any service industry to harness its self-interest and to act according to beneficence alone — to compete on true value when the opportunity to inflate perceived value is readily available.
Indeed! The entire article is highly recommended.
Thoughts?
(h/t Health News Review Blog)
