Should Dissent Be Allowed in Health Care?

An eminent physician has tentatively proposed that published treatment guidelines be accompanied by dissenting expert opinions, much like U.S. Supreme Court decisions.

Daniel Musher, MD, of Baylor College of Medicine, served on the Advisory Committee on Immunization Practice of the Centers for Disease Control and Prevention, which considered guidelines for a dual vaccine approach for pneumococcal vaccination for adults. He disagreed strongly with the published recommendation, but was prevented from publishing his opinion alongside the recommendation.

Dr. Musher believes the publishing of dissenting opinions is very valuable to the progress of knowledge:

As citizens of the United States, we are as much bound by a 5-4 decision of the High Court as a 9-0 vote (although closely passed decisions are more likely to be overturned in future cases).¹ Similarly, as practitioners of medicine, until new guidelines are written, we are seriously constrained by, if not actually bound by, existing ones, without regard to the unanimity of opinion in the recommending committee. Nevertheless, there is much to gain from studying dissenting opinions, as was famously shown by the writings of Justices Holmes and Brandeis, many of whose minority opinions, in time, became the law of the land.² I propose that the failure to publish differing or dissenting views in medical guidelines presents our profession with an inappropriately monolithic view—one that is studied as gospel by physicians-in-training and forced on practitioners by incorporation into a variety of performance measures.

This proposal seems very reasonable, especially in a time when expert guidelines determine the flow of billions of tax dollars and access to treatment. There was a lot of controversy circa 2009 and 2010, when the Affordable Care Act was passed, about whether women in their 40s would get “free” mammograms every year.

In 2009, the US Preventive Services Task Force issued guidelines recommending annual mammograms for women starting at 50 years, not 40 (as previously recommended). Needless to say, this change upset many people. The American Cancer Society maintained its recommendation that preventive screening start at 40, as did the Mayo Clinic. Politicians took note, and made an exception in Obamacare for mammograms, such that the 2009 USPSTF revision was ignored when it came to Obamacare’s “free” preventive care. (In January 2016, USPTF maintained is recommendation.)

We are entering a period when access to care will be centrally determined by political appointees who project an inappropriate degree of certainty when they issue their guidelines. They could at least allow dissenting experts the right be heard.