the ethics of prophylactic mastectomy

As I was reading this article by Jane Brody in yesterday's NYT, I began thinking about the notion of prophylactic mastectomy for women at increased risk of breast cancer. It's mentioned only in passing in this article ("Total mastectomy with reconstruction is becoming an increasingly popular choice, among women with breast cancer and among those with an unusually high risk of developing it."), but it seemed worth more thought.

Women can now be tested to determine whether they have the genetic mutations in BRCA1 and BRCA2 that are known to increase the risk of breast cancer. This testing isn't currently recommended for the general population--clinical breast exams and mammography are the standard screening recommended for the general population--but it might make sense for women who have a family history of breast and/or ovarian cancer. But some women do get tested and, upon finding out that they do have a very high risk of developing cancer, choose to have their breasts surgically removed. Some may also choose to have their ovaries removed, as the same genetic mutations that cause breast cancer can also cause ovarian cancer.

Random thoughts this rainy Saturday: Are there circumstances under which we could all agree that prophylactic mastectomy/oophorectomy makes sense? Would we base our decisions on clinical criteria, or other reasons? And are there other situations in which we would contemplate removing a body part because it could become diseased in the future?

Say we do agree: there are times it's a good idea to remove a so-far-healthy breast or two. What if a person finds out that she *doesn't* have an increased genetic risk, but is so frightened of breast cancer that she wants a mastectomy anyway? Should a surgeon refuse to do the procedure? If the surgeon refuses, and the woman later develops breast cancer, does she have a case against the surgeon?

Should insurance pay for the surgery in an average-risk woman? Could insurance require the surgery in high-risk patients? Could they say that a high-risk patient who refused surgery would be dropped from the plan? Might they say that if a high-risk patient opted not to have the mastectomy (which the insurer would pay for), and then developed breast cancer, it wouldn't pay for treatment?

As we move more and more toward a "personal responsibility" view of healthcare in the United States, we need to remain cognizant of the bigger picture. Today, the view that people are responsible for the unhealthy choices they make (smoking, drinking, using drugs, etc.) and should bear the burdens of their decisions is becoming more and more popular. It may turn out that when we began to think about this issue in terms of "health problems you choose for yourself," we may unwittingly have opened the door to such ideas as mandatory (if you want to stay insured) mastectomy.