Screening test might not be the ethical choice
Screening test might not be the ethical choice
Patients biased in favor of testing
In general, patients think of a screening test as a good thing, says Arthur L. Caplan, PhD, director of the Division of Medical Ethics at NYU Langone Medical Center in New York, NY. "Patients aapproach this thinking that it is better to test than not test, and doctors have to be aware of that bias," he says. "Unless a test hurts a lot, patients don't see any danger." The doctor has an ethical obligation to give accurate information about the risks and benefits of a test, including the fact that a test might be very inaccurate, he says.
The U.S. Preventive Services Task Force's 2009 guidelines say mammograms should not be done routinely for women ages 40-50. "The data doesn't seem to support it. But testing is still going on, even though the current recommendation is not to test women annually," Caplan says. "In the face of risk in our culture, we feel doing something is better than doing nothing." The same is likely to happen with PSA testing for prostate cancer, he adds, despite the United States Preventive Services Task Force's May 2012 recommendation that the widely used test no longer be used routinely for men of any age.1
Screening tests are useful to detect conditions with serious consequences in which there is a treatment that can change the course of a disease, and in which that treatment is more effective if the condition is diagnosed before symptoms occur or early in the disease process, according to Virginia L. Hood, MB.BS, MPH, MACP, professor of medicine at the University of Vermont and immediate past president of the American College of Physicians.
Hood says that an example of a "good" screening test is a colonoscopy to look for colon cancer in adults older than age 50 and some younger people with risk factors. Colon cancer is the second leading cause of cancer deaths in the United States, and screening has been shown to save lives by detecting cancers at an early stage or conditions such as polyps that can lead to colon cancer and can be removed before cancer develops, she explains.
"An example of a bad screening or diagnostic test is doing radiological imaging looking for the cause of uncomplicated low back pain," says Hood. Research indicates that these tests do not lead to better outcomes in terms of pain, function, quality of life, or overall well being, and were associated with documented harms such as low level irradiation, clinically irrelevant findings that lead to more unnecessary tests, and increased costs.2 Here are ethical considerations involving screening tests:
Physicians need to make it acceptable for the patient to conclude they don't want a test.
"Most people are going to assume the correct answer to 'Should I be tested?' is always going to be 'yes,'" says Caplan. "You need to document that discussion so there are no recriminations later. But in a way, you have to make it morally allowable to say no."
Doctors may need to explain, for instance, that a false-positive result means an intensive course of surveillance, including monitoring with potentially harmful biopsies and X-rays. "The doctor's job is to lay out the strengths and weaknesses of the test. At the end of the day, it's still up to the patient to decide how they want to proceed," Caplan says. "Some patients are going to say, 'Dying of prostate cancer is the worst thing I can imagine. I want to be tested, and I don't care if you have to monitor me with biopsy or risk impotence and incontinence.'"
Doctors need to be comfortable themselves with not ordering a screening test.
"A significant amount of testing is done for the practice of defensive medicine. It is not done for the patient, but for the doctor," says Caplan. "The doctor's fears might need to be calmed. Both the doctor and the patient need permission to say, 'It's all right to forgo the test.'"
Physicians and patients both need to consider the implications of false positives.
"The two tests most in the news today are screening for ovarian cancer and prostate cancer. Both have false positives," says Gregory R. Moore, MD, MPH, senior director of Stamps Health Services at Georgia Institute of Technology in Atlanta. "False positives are a little more complicated than they may appear."
The chance of a false positive for any one patient depends on the incidence of the disease or condition in the population being screened, so false-positive rates vary, he explains. Since no screening test is entirely accurate, physicians need to consider what is done with false positives. A positive screen for ovarian cancer requires a surgical evaluation of the ovary in question, for example.
"This next step has very clear surgical risks. Similarly, a positive test for prostate cancer requires a biopsy, which has clear risks," Moore says. "Even with a confirmatory positive biopsy for prostate cancer, we are still very limited in determining just how aggressive that tumor may be." Surgery for prostate cancer often causes incontinence and impotence, he notes. "These are obviously complications we would like to avoid when the tumor is not particularly aggressive. Prostate cancers that are not particularly aggressive can go for years or even decades without causing serious illness," says Moore. (See sidebar on ethical obligations involving patient education, below.)
References
- Screening for Prostate Cancer, Topic Page. U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm.
- Chou R, Qaseem A, Owens DK, et al. Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Ann Intern Med. 2011;154:181-189.
Sources
- Jeff Belkora, PhD, Associate Professor of Surgery, Institute for Health Policy Studies, University of California, San Francisco. Phone: (650) 533-6965. E-mail: [email protected].
- Arthur L. Caplan, PhD, Director, Division of Medical Ethics, NYU Langone Medical Center, New York, NY. E-mail: [email protected].
- Virginia L. Hood, MB.BS, MPH, MACP, Professor of Medicine, University of Vermont, Burlington. Phone: (802) 847-2534. E-mail: [email protected].
- Gregory R. Moore, MD, MPH, Senior Director, Stamps Health Services, Georgia Institute of Technology, Atlanta. E-mail: [email protected].
Fully informing patients on tests: "Ethical imperative" Paternalism "cropping up" in public health Well-informed patients choose less invasive screening and treatment than those who are acting on poor information or ill-considered preferences, according to Jeff Belkora, PhD, director of decision services at the UCSF Breast Care Center and associate professor of surgery at the University of California, San Francisco's Institute for Health Policy Studies. "Providers may protest that patient education takes time; it does. It's also a legal and ethical imperative known as informed consent, more properly thought of today as informed choice," says Belkora. "We must reform the financing of health care so that we are funding our legal and ethical mandates." Fully informing patients might cost hundreds of dollars, acknowledges Belkora. "But we squander orders of magnitude more than that on waste in medicine. We can afford fully informing and involving patients," he says. People may choose to do screening when fully informed, but it is not a prescription that fits everyone of any age or condition, says Belkora, and patient preferences matter, too. "We have mostly gotten past paternalism in medicine, but it is cropping up in public health," he says. "My ethical stance is that screening in general is overprescribed as a public health benefit. In fact, on an individual basis, there is usually some non-negligible risk of harm, while the chance of benefit is often low." Doctors and patients need to weigh how they feel about the value, timing, and likelihood of screening outcomes, at different ages and life circumstances, says Belkora. "There is a simple way to think about whether decisions should be highly individualized to patient preferences and circumstances," he says. In rare circumstances in which the benefits of intervention, including screening, vastly outweigh potential harms; and there is a strong evidence base, and little variation in how patients and providers feel about outcomes, this can be defined as "effective" care that needs to be more broadly disseminated, says Belkora.1 "Examples of these three conditions are hard to find in medicine, but might include using beta blockers to treat heart disease," he says. In most circumstances in medicine, however, patients risk significant harm along with benefits, or there is not a strong evidence base to rely on, or patients vary significantly in how they feel about the value, timing, and likelihood of the outcomes, says Belkora. "These cases are defined as 'preference-sensitive,'" he says. "Recommendations should be individualized to patients using shared decision-making strategies, such as clear risk communication and preference elicitation." If the patient is requesting a test that is clearly ineffective, in that harm vastly outweighs benefits, and there is a strong evidence base and there is a general consensus among well-informed patients and providers against the request, then the provider's obligation to beneficence may outweigh the provider's obligation to patient autonomy, according to Belkora. In that situation, the provider may refuse to administer the test out of a sense of professional responsibility. "However, in cancer care, this is a somewhat unlikely scenario," he says. "More likely, the provider must address the fact that patients are autonomous and have a legal and ethical right in our society to self-determination." Reference
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In general, patients think of a screening test as a good thing, says Arthur L. Caplan, PhD, director of the Division of Medical Ethics at NYU Langone Medical Center in New York, NY. "Patients aapproach this thinking that it is better to test than not test, and doctors have to be aware of that bias," he says.
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