Scanning for Health?

"Ignorance is bliss," say some doctors.

Today, modern technologies like multi-slice computed tomography (CT) can scan every organ in a person's body in fewer than 10 minutes. Such CT scans can detect tiny tumors or calcium buildup in arteries. So what's wrong with letting patients pay a few hundred dollars out of pocket for full-body scans that can reveal things like heart problems, brain tumors, or aneurysms? A lot, according to some public health officials and doctors.

Doctors oppose the widespread use of CT scanning on the grounds that no public health benefit has yet been demonstrated from using it. They note that no clinical studies have shown that using CT scanning to find early tumors actually increases patients' chances of survival. Of course, no studies have shown that CT scans don't save lives either. The use of CT is just too new for the requisite studies to have been done yet.

But what about private health benefits? Doctors working at scanning clinics like the Cooper Clinic in Dallas or MillenniumScan in Washington, D.C., can point to scores of patients whose lives were probably saved by early detection of cancer and heart problems. And what do the critics mean by "cost effective" anyway? One gets a hint when one hears public health officials faulting scanning clinics "for siphoning off scarce health care dollars." That criticism presumes that "resources" somehow belong to the health care system, rather than to the patients and doctors themselves. In fact, it's a lot more sensible to think that private scanning clinics are "siphoning" dollars from the makers of Porsches and destination restaurants.

But the opponents of CT scanning are probably right in the narrowest sense -- most people don't "need" a CT scan. However, blinded by their paternalistic assumptions, such opponents drastically discount the major benefit of CT scanning: peace of mind. I know whereof I speak. Four years ago, as a man in my 40s, I had begun occasionally to experience vague aches and pains. I realized that they were most likely the normal consequences of the slow deterioration that accompanies aging. Nevertheless, I fretted about them. So, even before CT scanning had become popular, I went to my doctor and told him I wanted a full-body scan. He sought to discourage me by telling me I would have to pay for it out of pocket, but I insisted. In those benighted days I had to get a doctor's referral since radiology clinics wouldn't take walk-ins like me.

I went in, got shot up with the contrasting agent that improves the imaging, and spent 15 minutes or so in a clanking machine. I paid a couple of thousand bucks for the privilege. A week or so later, the results were back and everything was normal. I felt great. It was the best $2,000 I had ever spent. Of course, I was aware that my scan could have been a false negative. Perhaps something was really wrong with me and the scan had missed it, but given my other tests that seemed unlikely.

False positives and false negatives are possible with CT scans, but the scans are still a helpful technology that gives patients more - though never perfect - knowledge about their health. They are a useful adjunct to, though not a substitute for, a complete checkup by a patient's physician. There are a variety of scanning technologies, some of which are better than others. In any case, newer, faster, and vastly more precise scanning machines will roll out in the next couple of years, which will significantly reduce diagnostic inaccuracies.

It's not surprising that doctors are predisposed to see CT scanning and other medical tests as primarily aimed at diagnosing illness. Proper diagnosis leads to proper treatments. However such tests can also be used to diagnose health. Health information is not just about deciding on treatments, but also can help people decide how they want to arrange their lives. For example, if a test reveals a genetic predisposition to early-onset Alzheimer's disease, a patient may decide to forego a career in tax law and become a scuba instructor in the Caribbean instead.

As the controversy over private CT scanning shows, nothing patients want to do without a doctor's permission ever goes without censure by the self-appointed gatekeepers of the medical profession. The CT scanning dispute is reminiscent of the debate in the 1990s over whether women should have access to the test for the BRCA breast cancer gene. Medical professionals were nearly unanimous that women should not be able to get a BRCA test on the grounds that, if it turned out they had the gene, there was no clinically validated treatment available.

Despite these pronouncements, many women pressed on, obtained the test, and if they found that they were at risk, chose to have mastectomies. Subsequent research has conclusively shown that mastectomies dramatically reduce a BRCA gene carrier's risk of getting breast cancer. Many women would have died had they waited until they got the gatekeepers' okay to proceed.

Despite decades of progress in empowering patients and breaking down medical paternalism, the impulse to limit patient's choices is still all too strong.