From Figures to Values: The Implicit EthicalJudgements in our Measures of Health
, School of Public Health, Imperial College LondonRoberto Satolli, Zadig, Milano Italy
Corresponding author: Paolo Vineis, School of Public Health, Imperial College London, St Mary’s Campus, Norfolk Place W2 1PG London.Tel:
44 (0)20 75943372; Fax:
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The objective of the article is to examine the extensions of a clinical measure of efﬁcacy, the Number Needed toTreat (NNT), in different settings including screening, scanning, genetic testing and primary prevention, and theassociated ethical implications. We examine several situations in which the use of the NNT or NNS (NumberNeeded to Screen) has been suggested, such as Prostate-Speciﬁc Antigen for prostate cancer, MagneticResonance Imaging scans, genetic testing and banning of smoking. For each application, we explore the ethicalimplications of the relevant measure. We have found that the different measures have different ethical impli-cations. For example, the Number Needed to Prevent is the only measure that can be lower than one, indicatingwith a numerical example that prevention is better than cure. Conversely, we raise questions about the accept-ability of genetic screening. In a realistic example, we show that primary prevention of the effects of arsenic indrinking water, targeted to the most susceptible, would require to genetically screen a large number of subjects,whereas giving rise to ethical concerns. We warn against the abuse of testing, in particular genetic testing, weshow that different measures are associated with different ethical issues and that prevention tends to be betterthan cure.
How the impact of medical and preventive activities ismeasured is one of the important issues that epidemi-ologists face, and it has moral implications. The purposeof this article is to show how different measures of treat-ment and prevention are associated with very differentimpacts for the populations involved, and entail differ-ent moral implications. For the aim of this analysis, any clinical or public health intervention can be consideredworthy on the basis of two ethical principles: (i) beneﬁtsshouldexceedharm(beneﬁcence)and(ii)thepriorityinthe use of public resources should be for interventionsthat produce more beneﬁts for more people (utility).
Number Needed to Treat
The Number Needed to Treat (NNT) is probably themostusefulsingleﬁgurethatoneneedstoknowinorderto judge the efﬁcacy of a therapy, and in fact of any medical intervention. Its properties have beendescribed—see (Schulzer and Mancini, 1996) and(Walter, 2001) for reviews and a discussion of statisticalaspects—and its use has thrived in the last decades—see(Zulman
, 2008) for an application to PublicHealth strategies. It is a summary measure that allowsthe physician to estimate how many patients need toreceive a treatment to have a beneﬁt, it can be comparedwiththeexpected burden ofside-effects, withalternativecourses of action, and can lead to a cost–beneﬁt analysis.However, its extensions to testing, screening, scanning(including incidental ﬁndings) and primary preventionhave not been fully explored and will be analysed herefrom a public health perspective.By examining different scenarios, we will address themoral implications involved in the use of the NNT andderived measures.
Scenario 1: Therapy and Tertiary Prevention
The NNT is the number of patients that is necessary totreat with a drug or any other medical intervention tosave one life, to avoid the loss of 1 year of life (or of oneQuality Adjusted Life Years (QALY)), or to reduce otherspeciﬁed adverse healthoutcomes.TheNNT(Box1)isafunction of the efﬁcacy of the therapy and of the fre-quency of the outcome we want to avoid or prevent.
PUBLIC HEALTH ETHICS VOLUME 5
The Author 2012. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org