The cost-effectiveness of prenatal screening for Down syndrome

Because the British National Health Service is a governmental single-payer system decisions about what is covered in that system involve public discussion. That leads to public discussion of ethical issues that frequently manage to avoid the public eye in the US. A recent article in the Daily Mail talks about an issue that is being debated by the British NHS. They are currently deciding whether noninvasive prenatal testing, also known as prenatal cell-free DNA screening should be covered by their health system and whether it should be covered only for those at high risk for chromosomal abnormalities or as a general screening test. This test identifies chromosomal abnormalities in a fetus more accurately than previously available screening tests, but is more expensive. The most common abnormality identified by this test is Down syndrome.

Some of those involved in this discussion have suggested, according to the Daily Mail article, that an analysis of the lifetime costs of caring for children with Down syndrome should be included in a cost-effectiveness analysis of whether this test should be provided for general screening. That suggestion has raised significant concern among parents who have children with Down syndrome. Their concern is based on a significant ethical issue. For the cost of caring for children with Down syndrome to be considered as a part of the cost-effectiveness of this screening test one would need to be balancing the cost of using this screening test for general screening against the costs of care that would be saved by the system not having to pay for the care of those fetuses with Down syndrome who were aborted. That means that a child with Down syndrome who is allowed to live is being seen as a financial liability to the system and that the cost of medical care for that child is being used to justify the cost of screening. What would be left out of such a cost effectiveness analysis would be the value of the lives of those children with Down syndrome. That is why the parents of children with Down syndrome are justifiably upset.

Cost-effectiveness analysis can be appropriate when we are comparing alternate ways to treat a disease or save a person’s life, but we need to be careful that what we are analyzing is the comparative costs of treatments that provide benefit to the person being treated. We should not do a cost-effectiveness analysis based on saving costs by ending the lives of those for whom we should be caring. This applies whether those lives are lost by abortion or by euthanasia.

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Mark McQuain
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Mark McQuain

Clearly, adding an additional cost of screening to the NHS can only be beneficial to the system if the NHS can avoid the lifetime medical costs of caring for those with Downs Syndrome. The only way these lifetime costs can be avoided is if those pregnancies with positive tests are terminated. The “benefit” demands an “abortion” for the utilitarian accounting to be useful. Think of the external pressure this puts on vulnerable families to do the “right” thing for the “benefit of society as a whole”. The only way this calculus would consistently fail is if the value placed on… Read more »

Jim Heid, MD
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Jim Heid, MD

I am a family physician who still delivers babies. I have the conversation BEFORE ordering the tests – about what the couple would do with the information. I have not personally experienced patients being pressured, but have heard of pregnant women being pressured to abort once a diagnosis of some type of anomaly is made. I would argue that you cannot measure the contribution of the life of a Down Syndrome individual, so there is no way to measure the cost-effectiveness of aborting that same individual. Therefore, skip the test! Also, if I have understood my reading, abortion for fetal… Read more »