The practice of paying women to undergo mammography is unethical, according to an opinion piece published in the September 8 issue of the Journal of the American Medical Association.
Cash payments for mammography screening range from $10 to $250 and are typically paid by insurance companies, wrote Harald Schmidt, PhD, from the Perelman School of Medicine at the University of Pennsylvania. The practice is part of a larger trend to give patients incentives toward healthy behaviors such as quitting smoking or losing weight (JAMA, September 8, 2015, Vol. 314:10, pp. 995-996).
Cash incentives for breast cancer screening can cause women to believe that mammograms are always beneficial, but there are some harms to screening: Not all women who are screened survive the disease, and some cancers are identified that never develop into fatal tumors, according to Schmidt.
"Incentives for having mammograms are ethically troubling," Schmidt said in a statement released by the University of Pennsylvania. "Women need to strike a delicate balance in assessing the benefits and risks of mammograms. ... But with breast screening, [incentivizing] mammograms can unhelpfully short-circuit decision-making."
In a study assessing decision aids, women who received brochures that enumerated risks and benefits of mammograms, such as the actual number of false positives, were less likely to have mammograms than women who received brochures that simply discussed the risk of false positives without actual figures to illustrate the scope of overtreatment (74% versus 84%), Schmidt wrote.
"Informed decision-making is important. But since better-informed women are less inclined to be screened, fewer breast cancer deaths will likely be averted," he said. "The question is: Should minimizing deaths from breast cancer be prioritized over maximizing informed decision-making, or vice versa?"
True consent requires an understanding of an intervention's risks as well as benefits, and as such, is it unethical to leave out key information, such as false-positive rates and information on overtreatment, Schmidt wrote. And because of the complexity of the data, information should be conveyed in ways that are understandable for patients of all levels of literacy and numeracy.
"Less-educated, lower-income groups face greater challenges because incentives, especially larger financial ones, have more salience for them and may unhelpfully shortcut informed decision-making," he said.
