Screening 15. May 2009

BMJ 2003; 327:

”To ask about the ethics of screening, generally aimed to make healthier people healthier, sounds, if not perverse, then definitely superflous.” Petr Skrabanek, 1994 in: ”The death of Human medicine - and the rise of coercive healthism.”

”To ask about the ethics of screening, generally aimed to make healthier people healthier, sounds, if not perverse, then definitely superflous.” Petr Skrabanek, 1994 in: ”The death of Human medicine - and the rise of coercive healthism.”

”Prevention is better than cure.”  ”Instead of pulling all these drowning people from the river, we had better find out who is throwing them in.”

Fiona Godlee, editor BMJ, 23. April 2005: ”The old adage ”Prevention is better than cure”… “… the excessive self confidence of preventive medicine, which is making us ill and miserable…”

”There is a view that there must be some gain from earlier diagnosis; awaiting trial results is a needless delay. The scientific rigour applied to other areas of medicine may not always be applied to screening.” Malcolm Law, BMJ 2004; 328: 301-2

Many people in the United States think that screening is a panacea, a way of warding off disease and staying healthy - perhaps forever. Those who question this fairy tale view, as we recently discovered, are considered traitors, or even murderers. Gavin Yamey and Michael Wilkes, editors of Western Journal of Medicine, California in BMJ 2002; 324: 431.

”Screening has become a marker for society’s commitment to women’s health.” Richard Horton, editor, Lancet

”In our desire for good population coverage we have said that screening is simple, effective, and inexpensive. In truth, it is complex, of limited effectiveness, and very expensive”. Angela Raffle on cervical screening programmes, 1995

UNESCO: Universal Declaration on Bioethics and Human Rights, 2005 Article 6 - Consent Any preventive, diagnostic and therapeutic medical intervention is only to be carried out with the prior, free and informed consent of the person concerned, based on adequate information...

Recommendations from The Ethical Council (1) Since invitations are uncalled-for health authorities have a particular obligation to inform carefully and in detail about screening programmes

Recommendations from The Ethical Council (2) The following should appear in the invitation: Number needed to screen for one to benefit The risks of false positive results (including the consequent requirement for extra examinations incurring new risks) The cumulated risk of false negative results

Recommendations from The Ethical Council (3) The following should appear in the invitation: Consequences for the participant. Relative reduction in mortality is not sufficient. Absolute reduction in mortality should be given Precise information of risks Voluntariness of participation

- Responses…

(1) ”When it comes to breast cancer screening we think that informing women of these risks of false screening results will create more insecurity and confusion than not informing.” Walter Schwartz, radiologist, 2000

(2) “We have discussed the matter in the region of Copenhagen hospitals but we have no plans of changing our politics of information. One might consider informing the women of the risk that cancers can emerge during the two years between screenings rounds. But my colleagues and I find it inappropriate and misleading to attempt to state a risk of wrong results in dry numbers.” Mogens Blichert-Toft, surgeon, (2000)

Law on legal status of patients §6: No treatment shall be initiated or continued without the informed consent of the patient… §7: The patient has a right to information of his or her health condition and of treatment possibilities including information of risks of complications and side effects.

Law on legal status of patients §7, subs. 5: ”If the patient is judged to be ignorant of matters that are important for decisions as to consent, cf. § 6, the health servant shall give this information unless the patient has declared that he or she do not want it.”

Law on legal status of patients §7, subs. 5: ”If the patient is judged to be ignorant of matters that are important for decisions as to consent, cf. § 6, the health servant shall give this information unless the patient has declared that he or she do not want it.”

… It is a daring contention that the patient should not consider the risks of false test results important for his or her decisions as to comply…

”Because it is acted on healthy people, preventive medicine needs even stronger supporting evidence on benefits and harms that therapeutic interventions. And, for a new age, we need new adages. But will they have the same ring to them? Prevention may not be better than cure. A stitch in time may in some cases be unnecessary and harmful...”

” Credo in unam veritatem… [I believe in one truth!] ’Find it early!’ And lo they come, and they do find it early, and women everywhere rejoice and say: ’My life was saved!’” Hazel Tornton

Screening problems false-negative results false-positive results the level of expertise in large screening centres as compared with specialized units

BMJ 2003; 327: