in trials known as TAILORx and MINDACT to
Cancer and Society
see whether they are able to identify the most
But what does all this information mean for
appropriate and effective treatments for patients
society? The financial costs of cancer loom large,
(NCI, 2012a).
not only for individual patients and their families
but also for the general public and society. NCI
Molecular fingerprinting is also allowing
estimated the overall annual costs of cancer
re searchers to develop new treatments specifically
in the United States at about $267 billion in
targeted at molecular subtypes of different
2010. This cost includes about $124.6 billion for
cancers. Often, tumors that are indistinguishable
direct medical costs and $142.4 billion for lost
by tra ditional criteria nevertheless respond
productivity due to premature death (NCI, 2011;
Bradley et al., 2008). Treatment costs for the four
32
most common cancers (breast, lung, colorectal,
Figure 7. A history of severe sunburns in childhood is
and prostate) were almost one-half (44 percent)
strongly linked to the development of skin cancer later
of the direct medical costs for all cancers (NCI,
in life.
2011).
Although early detection and successful treatment
can reduce cancer deaths, preventing cancer
in the first place would be most efficient. The
American Cancer Society reports that “cancers
that can be prevented or detected earlier by
screening account for at least half of all new
cancer cases” (ACS, 2011).
The persistence of unhealthy habits among
Americans is widespread. Part of the reason
A third level of prevention is the national
may be that the only data we have about
level, where government agencies can impose
factors related to cancer are drawn from whole
regulations that help minimize the public’s
populations. These data cannot tell us who will
exposure to known carcinogens and implement
develop cancer. Nor can they tell us whether
policies that improve public health. Examples
healthy choices prevented its appearance in a
include regulating industries to cease using potent
particular individual.
carcinogens and providing community facilities
for safe physical activity.
Unhealthy habits may also persist because of the
long time that elapses between the exposures
Finally, a fourth level of prevention is at the
that trigger the development of cancer and its
international level, where the actions of developed
actual appearance as disease. Conversely, there is
countries can affect the incidence of cancer
a time lag between the institution of a beneficial
worldwide. Unfortunate counter-examples of this
personal habit (such as quitting smoking) or
include such countries allowing or promoting the
public policy (such as a ban on smoking in public
export of tobacco products and moving hazardous
spaces) and its positive impact on personal and
manufacturing processes to developing countries,
public health.
where they may not be regulated.
In their article “Strategies for minimizing cancer
How do we think about devising and
risk,” Willett, Colditz, and Mueller (1996)
implementing measures to improve personal
proposed four levels on which to focus cancer
and public health in a pluralist society? One way
prevention efforts. The first level is that of the
to address this question is by attending to the
individual. These authors argue that because most
ethical and public policy issues raised by our
of the actions that can prevent cancer must be
understanding and treatment of cancer.
taken by individuals, dissemination of accurate
information directly to the American public,
Ethics is the study of good and bad, right and
together with peer support for behavioral changes,
wrong. It has to do with the actions and character
is critical.
of individuals, families, communities, institutions,
and societies. During the past 2,500 years,
A second level is healthcare providers, who are
Western philosophy has developed a variety of
in a position to provide both counseling and
powerful methods and a reliable set of concepts
screening to individuals under their care. Here,
and technical terms for studying and talking
dissemination of accurate and timely information
about the ethical life. Generally speaking, we
is also key.
apply the terms “right” and “good” to actions and
qualities that foster the interests of individuals,
families, communities, institutions, and society.
33
Understanding Cancer
Cell Biology and Cancer
Here, an “interest” refers to a participant’s share
values that students may appeal to in discussions
in a situation. The terms “wrong” or “bad” apply
of ethical issues include autonomy, freedom,
to actions and qualities that impair interests.
privacy, sanctity of life, protecting another
Often there are competing, well-reasoned answers
from harm, promoting another’s good, justice,
to questions about what is right and wrong and
fairness, relationships, scientific knowledge, and
good and bad about an individual’s or a group’s
technological progress.
conduct or actions.
Acknowledging the complex, multifaceted
Ethical considerations are complex and
nature of ethical discussions is not to suggest
multifaceted, and they raise many questions.
that “anything goes.” Experts generally agree on
In the United States, for example, we value
the following features of ethics. First, ethics is
protecting individuals from preventable harms.
a process of rational inquiry. It involves posing
We support restrictions on who can purchase
clearly formulated questions and seeking well-
cigarettes and where smoking can occur. We
reasoned answers to those questions. Well-
inform pregnant women of the risks of drinking
reasoned answers to ethical questions constitute
and smoking. However, we also value individual
arguments. Ethical analysis and argument, then,
freedom and autonomy. We do not ban cigarettes
result from successful ethical inquiry.
outright; instead, we allow individuals over 18
years of age to take personal risks and be exposed
Second, ethics requires a solid foundation of
to the related consequences. We permit pregnant
information and rigorous interpretation of that
women to buy and use liquor and cigarettes.
information. For example, one must have a solid
understanding of cancer to discuss the ethics
The inevitability of ethical tradeoffs is not simply
of requiring protective covering to be worn
an issue in the United States. When considering
to prevent skin cancer. Ethics is not strictly a
differing health-policy issues between and among
theoretical discipline but is concerned in vital
countries, one cannot avoid encountering a
ways with practical matters.
diverse array of ethical considerations. Developing
countries, whose health standards often differ
Third, because tradeoffs among interests are
from those in the United States, provide different
complex, constantly changing, and sometimes
cultural approaches to cancer and different
uncertain, there are often competing, well-
standards for marketing and using tobacco
reasoned answers to questions about what is
and other known carcinogens. These different
right and wrong and good and bad. This is
approaches raise a variety of ethical questions.
especially true in a pluralistic society.
For example, is there any legal and ethical way
Public policy is a set of guidelines or rules that
for people in the United States to prevent the
results from the actions or lack of actions of
widespread use of tobacco in other countries,
government entities. Government entities act
a practice that contributes to the rise of lung
by making laws. In the United States, laws
cancer worldwide? Is there any legal and ethical
can be made by each of the three branches of
way to govern other choices of individuals (for
government: by legislatures (statutory law), by
example, poor diet and lack of exercise) that may
courts (case law), and by regulatory agencies
contribute to cancer?
(regulatory law).
Typically, answers to such questions all involve
Regulatory laws are written by the executive
an appeal to values. A value is something that
branch of the government, under authorization
has significance or worth in a given situation.
by the legislative branch. All three types of law
One of the exciting aspects of any discussion
are pertinent to how we respond to cancer. When
of ethics in a pluralistic society is the variation
laws exist to regulate behavior, public policy is
in how the individuals involved assign value to
called de jure public policy.
things, people, and states of affairs. Examples of
34
When deciding whether to make public policy,
and 4) means are already in place for additional
one should consider at least the following
restrictions. The challenges in this era of high
five points:
economic interest in cigarette production are the
• costs of implementing particular policies
social, cultural, and political considerations (5).
(including financial, social, and personal costs);
• urgency of implementing a new policy;
It is important to recognize that sometimes the
• how effective a particular policy is likely to be;
best public policy is not to enact a law in response
• whether appropriate means exist to implement
to a controversy but rather to allow individuals,
the policy; and
families, communities, and societies to act in
• social, cultural, and political factors.
the manner they choose. Clearly, de jure public
policy can only go so far in regulating people’s
For example, many argue that there is over-
behaviors. De jure public policy in the United
whelming evidence to support a public policy
States offers no match for the addictive power of
of increased restrictions on access to and use
nicotine and the marketing clout of the tobacco
of cigarettes. Cigarette smoking is linked to 85
industry. In addition, any decline in cigarette
to 90 percent of lung cancer cases, and it leads
use brought about by de jure public policy in the
to chronic lung disease and heart disease. For
United States has been more than offset in recent
2012, 226,160 new cases of lung cancer were
years by a rapid increase of cigarette consumption
predicted, as were 160,340 deaths due to lung
elsewhere in the world.
cancer, lung disease, and heart disease (ACS,
2012). Public policy prohibitions on cigarette
When no laws exist to regulate behavior, public
use and access may be seen to satisfy four of
policy is called de facto (actual) public policy.
the five considerations: 1) the cost of the policy
With regard to lung cancer prevention programs,
would probably be minimal because cigarette
many think that other approaches are needed:
access and use restrictions are already in place,
improved general education and cultivation of an
2) the urgency of the situation is serious given
antismoking ethos. In any discussion of society’s
the large number of deaths and severe illnesses,
response to a social problem, it is important to
3) prohibiting purchases by minors and raising
think not just about laws, but about other ways to
prices (through taxation) are seen as effective,
address the problem.
Science plays an important role in helping
Figure 8. Where do we spend our money? A consequence
individuals make choices about enhancing
of allowing unhealthy habits, such as smoking, is
personal and public welfare. Science provides
that public funds may be spent on cancer treatments
evidence that can be used to support ways of
instead of on other societal benefits, such as improved
understanding and treating human disease,
school facilities.
illness, deformity, and dysfunction. But the
relationships between scientific information
and human choices, and between choices and
behaviors, are not linear. Human choice allows
individuals to choose against sound knowledge,
and choice does not necessarily lead to
particular actions.
Nevertheless, it is increasingly difficult for most
of us to deny the claims of science. We are
continually presented with great amounts of
relevant scientific and medical knowledge. We
are fortunate to have available a large amount
of convincing data about the development,
nature, and treatment of particular cancers.
35
Understanding Cancer
Cell Biology and Cancer
As a consequence, we might be encouraged to
One of the goals of this module is to encourage
think about the relationships among knowledge,
students to think in terms of these relationships,
choice, behavior, and human welfare in the
now and as they grow older.
following ways:
knowledge (what is and is not known) + choice
= power
power + behavior = enhanced human welfare
(that is, personal and public health)
36
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