Please, don’t throw tomatoes yet! Everybody knows that prevention in the twentieth century, particularly due to use of infectious disease vaccines and more recently some innovative invasive procedures, has changed the demographic face of our population and the world’s.

Of course, while what “everybody” knows is never the whole of the matter, the inspiring story of diagnosis, followed by treatment, followed by survival is a wonderful sequence of events.

An upcoming symposium is about the flip-side of that coin (although it has been very hard to get people to talk about it). About eighteen months ago, we chose to bring together scholars who don’t necessarily presume that the mainstream health care perspective of diagnosis and follow-up treatment is more than a single widely endorsed perspective. The upcoming symposium, part of the annual series on health/disability/elder law held by Marquette’s Elder’s Advisor law review, proposes that prevention is often enough overrated that close examination is warranted. The symposium is titled “The Institutionalization of Prevention: We Win, We Lose.”

Cancer diagnosis and treatment is particularly, but hardly exclusively, illustrative.

Shortly after planning for the meeting, federal agencies stated or reiterated some reservations about screenings. Most notably, the Preventive Services Taskforce has recommended abbreviated screenings – starting later, less often – for breast, cervical, and prostate cancer. This month, the professional American Cancer Society restated its recommendation against routine blood screening for prostate cancer and urged doctors to talk frankly with patients about the limits of testing and the possible results of treatment – impotence and incontinence.

This is a condensation of widely available information, but the commentary on it is revealing. In the context of high health care costs, physician reimbursement changes, and flagging trust between physicians and patients, the recommendations are interpreted by some as a willingness to let disease develop, leading to selective patient suffering and death. In a health care system in which necessary treatment is unavailable to too many, these concerns can only be expected. On the other hand, overaggressive treatment has caused great suffering and, in the case of some screenings and subsequent treatments, has not reduced the rate of mortality – the time of death for the treated versus the untreated patient. These are generally stories told in quieter voices. (See, for example, Nortin M. Hadler, Worried Sick: A Prescription for Health in an Overtreated America, University of North Carolina Press, 2008.)

A great part of the issue is risk aversion, or fear, among patients who might previously have been, or considered themselves, to be healthy in all major respects. Because of fear of pain or death that would deprive their families or frustrate other goals, individuals have chosen invasive, preventive surgery when the harm of disease is quite speculative. Indeed, with genetic testing, people have chosen aggressive surgery when their chance of ever getting the disease to be prevented is projected to be less than fifty percent.

Many people experience fear and submit to waves of increasingly invasive testing and surgery after screening and diagnosis. Even at the threshold of diagnosis, perhaps in the ER for pain, a patient too-often is told, “This could be invasive cancer.” Indeed, it could be, but, as the paradigm of informed consent dictates, remote risks need not be discussed, and the likelihood is generally low.

Reevaluation of the ways medical treatment decisions are made is fundamental to improving the quality of care (see, for example, Woloshin, Schwartz and Welch, Know Your Chances: Understanding Health Statistics, Univ. of California Press, 2008).

The error of over diagnosis or treatment is well known in such common parlance as “the breast cancer scare.”  It has become more likely to occur with tests that identify particular markers that might, but don’t necessarily, indicate dangerous disease. It may tie into a particularly American identification with health and youthfulness as moral issues; one must be restored to goodness whenever and as soon as possible. In addition, the aspirational values of physicians might be at issue, causing them to seek intervention when it is possible.

The merits of particular preventive measures require a close look at the health care industry, at the real extent of the patient’s opportunity and responsibility to assess and decide, and at the extent to which health care research focuses on the real need for and benefits of such measures. The questions are complicated, which is not a reason to shy away, but every reason to take up this matter.