The diffusion of medical technology is largely determined by the marketplace demands supported by national and historical contexts. Using the cases of cesarean delivery and newborn intensive care in the United States, this article presents the argument that the interaction of four factors accounts for the rapid diffusion of untested technologies. These factors are economic expansion in an unrestricted market, the vulnerability of the patient population, a social disposition towards emergency medicine, and the vested interest of medical specialists.

In this commentary on the previous paper it is explained that screen-detected Duct Carcinoma In Situ is effectively a new disease of unknown natural history. It is therefore impossible that 'the doctor knows best' and it is therefore both in the patient and the public's best interests that such cases are submitted to the rigours of the randomised controlled trial. Inevitably this brings the ethical dilemma of how to explain to patients the uncertainty and how to involve them in a (...) rational decision to take part in the randomised controlled trial. It is argued that as well as there being a collective benefit for future generations of women, that we should resolve this problem now, the individual woman is likely to benefit from being treated according to a strict protocol. Nevertheless the time of diagnosis is paradoxically not the best time for a patient to become aware of these matters and it is about time that the lay public and the opinion formers recognized their responsibility to become acquainted with the benefits and the needs of the randomised controlled trial in anticipation of the day when they themselves will be patients. (shrink)