The questionable ethics of incentivizing mammography screening

Who doesn’t like getting things for free? It’s even better when the freebies are used to incentivize patients to quit smoking or eat healthy. But should those gift cards, event tickets and t-shirts be used to get women to come in for a mammogram?

Harald Schmidt, PhD, MA, assistant professor of medical ethics & health policy at the University of Pennsylvania in Philadelphia thinks the answer is no, calling incentives for mammograms an “ethically disconcerting distraction in a complex decision-making process” in an editorial written for JAMA.

There are a few issues, according to Schmidt. First, mammography is no guarantee and some will be screened but still die from breast cancer. Also, unlike incentives for smoking cessation, which carries no risk and is all benefit for a patient, there are some risks of mammography screening. Overdiagnosis of cancers that won’t lead to deadly tumors can trigger unnecessary treatments that present their own harms. There’s also the issue of patient anxiety due to false positives.

Schmidt noted that the magnitude of the risks from overdiagnosis and anxiety is a matter of some disagreement, but it’s clear that there’s some tradeoffs being made.

Reduced screening rates could limit the number of breast cancer deaths averted, Schmidt concedes, but given the tradeoffs, current ethics calls for patients to be engaged in informed decision making. Evidence-based information suitable for all levels of literacy and numeracy should be provided.

And here’s where the freebies come in, wrote Schmidt. Not as a way of compelling women to undergo screening mammography, but as a way for payers to encourage use of decision aids whether or not the patient ultimately decides to follow-through with screening.

“Doing so promotes autonomy by minimizing regret that may result both from having and not having undergone screening,” wrote Schmidt. “Incentivized active choice can furthermore assist with reducing disparities between income and educational groups.”