When Values Collide: The Individual Versus the Common Good

Maurie Markman, MD

It is perhaps a little unusual that an oncol­ogy commentary would begin with a highly provocative discussion about the future of driverless cars¹, but there are similarities in the sharp corners of the debate over this new technology and emerging trends in cancer care.

A particularly thorny issue concerning driver­ less vehicles relates to design requirements for the automatic safety features. If a crash is about to occur (perhaps caused by reckless driving of a human who has had far too much to drink), an algorithm will “make decisions” as to the opti­mal course of action. One of the most important decisions in the development of the system’s logic would be the priority given to specific impacted groups. Should the goal be to program the onboard computer to take evasive action de­signed to minimize the risk of serious injury or death independent of the specific danger to the passengers in the driverless car itself? Or should the highest priority be to minimize the risk to that car’s passengers?

Many Oncology Examples

In a research project designed to address the question of how drivers would respond if asked what they believed to be the top priority, most respondents agreed that the ethically correct ap­proach would be to minimize risk for all potential­ly involved in an unavoidable accident or crash, independent of the specific risk to the individuals in the car in which they were a passenger. Howev­er, when asked if they would purchase a car with this particular built­in feature, the answer was, "No." Although they fully recognized that a partic­ular action may be best for the entire population, that action may not be optimal for the individual and therefore would not be acceptable.Conflict between the individual and the group has a constant presence in oncology. One example is the ever­-present, intense debate about the staggering increases in the costs of medical insurance—which spreads the financial risk across a large population—and the natural desire of individuals with cancer to have their third­ party payer agree to pay for all interventions and services that may favorably impact their outcome regardless of the cost to the insurance plan.

Another example of the tension between the individual and the group is vaccination for the sexually transmitted human papillomavirus, which has been unequivocally confirmed as a highly effective strategy to prevent cervical cancer and a large percentage of oropharyngeal malignancies. Society will benefit greatly by having a lower burden of these cancers, but only if individuals agree to be vaccinated.

A recently reported comprehensive review of the growing problem of endometrial cancer in the United States is another poignant illustration of this tension.² It is estimated that the incidence of this malignancy will increase by 55% to 42.13 cases per 100,000 women over a 20­-year period (2010 to 2030). The major culprit in this develop­ment appears to be the growing obesity epidemic, which is believed to be responsible for approxi­mately 60% of cases. Not only do women who are overweight have an increased risk of developing endometrial cancer, but their prognosis is sub­stantially worse in the presence of severe obesity.

Does an individual woman who is obese have any personal responsibility to attempt to lose weight to reduce her risk of endometrial cancer, recognizing societal obligations to pay for the costs of care for this strongly obesity-­related malignancy?

Population-Based Views

This question is quite similar to that which could be addressed to a heavy cigarette smoker, where the substantial healthcare­-related costs associated with the multiple medical conditions related to this habit, such as cardiac and respiratory dysfunction and cancer, may have to be borne by society as a group. In this situation, however, it might be argued that cigarette taxes and potentially higher charges associated with buying medical insurance will help compensate for societal obligations.Another level of tension regarding an individual versus the group relates to what might be viewed as following potentially acceptable population­ based outcomes, even if a small number of individuals may be harmed.

An example of this effect can be seen by examining the results of the risk and impact of severe neutropenia in patients undergoing chemotherapy for breast cancer.³ The analysis was conducted to determine the benefits of employing prophylactic granulocyte colony­-stim­ulating factors (G­CSFs) with several commonly used chemotherapy regimens in this setting. The major clinical outcomes examined were the development of neutropenic fever or hospitaliza­tion related to infection.

The decreased risk of neutropenia­-related hospitalization with the prophylactic delivery of G­CSF was 3­-fold for docetaxel plus cyclophos­phamide (TC) compared with no use of this agent (2.0% vs 7.1%) and almost 6­-fold for docetaxel plus carboplatin and trastuzumab (TCH) com­pared with no G­CSF use (1.3% vs 7.1%).

On a broad population basis, investigators con­cluded that 20 patients would have to be treated with TC for 21 days to avoid 1 neutropenia­-re­lated hospitalization and 18 patients would have to receive TCH for 21 days to achieve a similar result. They concluded that “primary G­CSF prophylaxis was associated with low-­to-­moderate benefit in lowering neutropenia-related hospi­talization in patients with breast cancer who received TC and TCH regimens.”³

Yet although the total number of patients bene ting may have been “modest” (<6% of all patients receiving G&shy;CSF), the favorable outcome was presumably quite meaningful for those individuals who avoided hospitalizations and complications of the infectious events. So how should one label the utility of this therapy if even 1 additional person out of 100 neutropenic patients who did not receive G&shy;CSF died?

How would you respond regarding the benefits of G&shy;CSF if this were your relative who was not a passenger in a driverless car, but a patient un&shy;dergoing therapy with TCH for breast cancer?

Maurie Markman, MD, editor-in-chief, is president of Medicine & Science at Cancer Treatment Centers of America, and clinical professor of Medicine, Drexel University College of Medicine. maurie.markman@ctca-hope.com.

References

1. Shari A. Whose life should your car save? New York Times. November 6, 2016:SR9.
2. Onstad MA, Schmandt RE, Lu KH. Addressing the role of obesity in endometrial cancer risk, prevention, and treatment. J Clin Oncol. 2016;34(35):4225-4230. doi:10.1200/JCO.2016.69.4638.
3. Agiro A, Ma Q, , Acheson AK, et al. Risk of neutropenia-related hospitalization in patients who received colony-stimulating factors with chemotherapy for breast cancer. J Clin Oncol. 2016;34(32):3872- 3879. doi:10.1200/JCO.2016.67.2899.