Angelina Jolie has now ignited a world-wide debate on Preventive Surgery. Can Surgery be really preventive? Is it worth going under the knife and suffer serious mutilation, only to prevent a disease, which may or no may not happen? Is it really wise to take the risk of surgery, when one is perfectly healthy, just to beat the odds that may or may not even exist? Where is medicine headed?
Angelina Jolie believed that she had a very high chance of developing breast cancer. She had seen her mother suffer and die from the dreaded disease, research indicates that it is possible to inherit breast cancer and she was given some fantastic odds of developing breast cancer in the future. From her perspective, she took the right decision of going ahead with a double mastectomy to beat what she believes are near certain odds of developing breast cancer. At the end of the day, it is her body and she has every right to undergo a surgery that she feels will help her prevent a deadly disease in the future. Anybody who has a quarrel with this position, I believe really has no case.
However, this does throw up interesting questions.
First let us begin with the odds that were offered to Ms. Jolie. I am not sure if we have enough data to give iron-clad probabilities of developing a disease. Science hasn’t really progressed, where it can say with reasonable certainty that an individual will develop a cancer with pin-point accuracy. Thus, how right it is to tell Ms. Jolie that the chances of her developing breast cancer are in the upper nineties. The number crunching at the end of the day is still really number crunching only. To decide to operate based on nebulous odds is hard to justify. Wouldn’t regular screening through high-end mammogram suffice? Do doctors now have the ability to look at the crystal ball and predict the future occurrence of a disease with near certainty? I am not so sure at all.
Second, does this mean that now many women with a history of this and other dreaded diseases opt for preventive surgical interventions? More importantly, is such aggression right? I believe this may trigger an avalanche of unnecessary surgery. As it is, the worst kept secret in medicine is that the quantum of surgery we presently do is much more than what is really needed. Now, with patients asking doctors for preventive surgical interventions, where are we really headed? The surgeons, who would want to be more prudent, may lose out on surgical work as their more scalpel happy colleagues will be happy to take up cases refused by their more conservative colleagues. Since, patients themselves will be keen on surgical interventions, it would really take a lot for a surgeon to say that he won’t operate because he believes surgery is not indicated. Do we really need this situation, where surgeons may be operating only because patients are keen on it !
Third, isn’t there a moral dimension to preventive surgeries as well. Performing surgery on a healthy individual, who may develop a disease later in life is fraught with moral hazard. Every surgery howsoever small comes with an inherent risk. The risk is of human error as well as of infections and unexpected complications. Should a healthy individual be subject to these risks in the here and now, only to prevent what may happen in the future? In Ms. Jolie’s case, mastectomy and subsequent reconstruction of the breasts are fairly complex surgeries. They do run significant risks. Are these risks higher or lower than those represented by the occurrence of breast cancer in the future?
Finally, who should decide whether a preventive surgery is needed or not. Should a patient ask for it, pretty much like a preventive health check. Should a surgeon operate, only because the patient is keen on it?
In my view there shouldn’t be anything called Preventive Surgery. We should operate to cure and not prevent future events. The fear of an uncertain future, must not dictate what we do in the present. This is where, I stand on this debate.