Academic journal article The Hastings Center Report

Medical Screening and the Value of Early Detection

Academic journal article The Hastings Center Report

Medical Screening and the Value of Early Detection

Article excerpt

When Unwarranted Faith Leads to Unethical Recommendations

One of the basic principles of medical ethics is Primum non nocere, or "At least do no harm." One of the basic claims of this essay is that many of our current screening practices are inconsistent with this principle.[1]

To screen is to search for disease in the absence of symptoms or, in other words, to attempt to find disease in someone not thought to have a disease. Examples of screening include routine mammography to detect breast cancer, routine pap smears to detect cervical cancer, routine prostate-specific antigen (PSA) testing to detect prostate cancer, and routine blood-cholesterol checks to search for signs of heart disease. Screening programs occur when large populations are encouraged to be screened for a particular disease at predetermined intervals and follow-up procedures are offered to those who test positive.

Screening tests and programs represent a relatively new mode of medical practice, in contrast to the more traditional mode of investigation and treatment. To investigate is to search for disease in someone suspected of having a disease, most likely because the person presents symptoms, but also because, for example, the person reports a strong family history of the disease. Thus taking an x-ray of the chest of a heavy smoker who reports a persistent hacking cough is an instance of investigation, as is doing a mammogram on a woman who has found a lump in her breast or who reports that her mother died of the disease. In short, physicians have traditionally ministered to those who are either known or suspected to be sick. With the development of screening tests and programs, they also try to help people who appear to be healthy by detecting and treating disease in its presymptomatic stages.

Numerous ethical questions can be raised about the practice of screening for disease. My focus is on the ethical permissibility of the current practice of recommending screening tests in the absence of randomized, controlled clinical trials (or other clear evidence) showing that the tests are actually likely to be beneficial, on balance, for those who take them. After providing some examples of this practice I suggest that our willingness to recommend the screening in these circumstances is grounded on an assumption about the value of early detection--namely, that the earlier a disease is detected the better it is for the patient. I then challenge that assumption by arguing that it cannot be presumed to be true in all cases and that in the cases in which it is true, it is inadequate to justify a screening recommendation. One central problem is that the assumption focuses solely on the benefits for the sick and ignores the risks to the healthy. I then consider two other justifications for the practice of recommending screening tests prior to the completion of randomized clinical trials. The first focuses on evidence from other sources and the second turns on the recipients' consent to the test. I argue that neither justification is successful and conclude that much of what is currently done in the name of medical screening is not just medically unwarranted, but morally unjustified as well.

Before turning to these matters, a few points of clarification are in order. First, I will be concerned with screening tests only insofar as they are recommended to asymptomatic individuals. I will not be concerned with tests that may be available but are not recommended, such as screening for the breast cancer gene. Second, I will be concerned primarily with broad, population-based screening recommendations (for example, that all men over age fifty get a certain test) rather than recommendations made by an individual practitioner to an individual patient, except where the latter is motivated by a population-based recommendation. Third, I will be assuming that a necessary condition for an ethically justified screening recommendation is that the test reasonably can be expected to be beneficial on balance for the person taking it. …

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