Is screening ethical

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of screening programmes; and (3) the possible psychological side effects of screening on
the individual. These criticisms constitute what can be seen as a backlash against the
screening of populations.
Is screening ethical?
Debates about the ethical issues surrounding screening have traditionally been polarized
between what Sackett and Holland (1975) referred to as ‘the evangelists and snails’.
These debates are best understood within the context of the four major ethical principles relating to decision-making principles in medicine: beneficence, non-maleficence,
autonomy and justice.
Beneficence – screening as beneficial to the patient
Beneficence refers to the likelihood that any benefits to the patient will outweigh any
burdens. Screening should therefore bring about benefits to the patient in terms of
detecting a treatable disease or abnormality and enabling the individual’s life to be
prolonged or enhanced. There is evidence both in favour and against screening as a
benefit to the patient.
Evidence for beneficence In terms of screening for hypertension, Hart (1987) has
argued ‘we are surely under a moral if not legal obligation to record blood pressure at
least once in every 5 year span for every registered adult in our practice’. In terms of
cervical screening it has been estimated that for every 40,000 smears, one life has been
saved (Lancet 1985). In terms of breast cancer, reports from the Health Insurance Plan
Study (Shapiro et al. 1972; Shapiro 1977) suggested that early detection of breast cancer through screening reduced mortality in the study group compared with the control
group by 30 per cent. Results at follow-up indicated that the study group were still
benefiting after 12 years (Shapiro et al. 1982). Further results concerning the benefits of
breast screening have been reported following a large random controlled trial in Sweden
(Lundgren 1981). Hinton (1992: 231) concluded from his review of the literature that
‘lives may be saved by annual mammographic screening’. Jones (1992) argued that
screening for colorectal cancer may also be beneficial. He suggested that the ‘evidence
and arguments . . . are becoming compelling’ and noted that the death rate due to
colorectal cancer was ten times that due to cervical cancer, for which there is an existing
screening programme. In addition, the identification of the absence of illness through
screening may also benefit the patient in that a negative result may ‘give health back to
the patient’ (Grimes 1988). Therefore, according to the ethical principle of beneficence,
screening may have some positive effects on those individuals being screened.
Evidence against beneficence Electronic foetal monitoring was introduced as a
way of improving obstetric outcomes. However, the results from two well-controlled
trials indicated that such monitoring may increase the rate of Caesarean section without
any benefit to the babies both immediately after birth (MacDonald et al. 1985) and at
4 years of age (Grant and Elbourne 1989). In addition, electronic foetal monitoring
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appeared to increase the rate of cerebral palsy measured at 18 months of age (Shy et al.
1990). In a recent review of the effects of antenatal blood pressure screening on the
incidence of pre-eclampsia (high blood pressure in pregnancy, which threatens the
mother’s life), the authors concluded that the introduction of antenatal screening has
had no significant effect on pre-eclampsia, suggesting that this screening process
does not benefit the individual. Recent papers have also questioned the efficacy of
screening for congenital dislocation of the hip in neonates (Leck 1986), hypertension,
breast cancer and cervical cancer in terms of the relative effectiveness of early (rather
than later) medical interventions and the effects of simply increasing the lead time (the
period of time between detection and symptoms).
Non-maleficence – screening must do no harm
Skrabanek (1988) suggested that screening should be subjected to the same rigours
as any experimental procedure, that the possible risks should be evaluated and that
the precept of ‘first do no harm’ should be remembered. Therefore, for screening
to be ethical, it must not only benefit the patient, but it must also have no negative
consequences either to the individual or to society as a whole. The psychological
and financial consequences of screening will be dealt with under later headings.
However, screening may cause personal harm in terms of biological consequences
and false-negative (receiving a negative result when the problem is actually present)
or false-positive (receiving a positive result when the problem is actually absent)
results; it may also cause social harm in terms of the medicalization of populations and the exacerbation of the existing stigmatization of certain groups of
individuals.
Personal harm Some of the techniques used to monitor an individual’s health may
have a detrimental effect on their biological state. This is of particular concern for
the frequent use of mammography for the detection of breast cancer. Evidence for the
harmful effects of the irradiation of breast tissue and the links to cancer can be found in
reports of breast cancer in women who have been treated for benign conditions using
radiation therapy (Metler et al. 1969; Simon 1977), in survivors of the bombings
of Hiroshima and Nagasaki (Wanebo et al. 1968) and in women who have been
given fluoroscopy for tuberculosis (MacKenzie 1965). It has been argued that there is a
threshold, below which radiation could be considered totally safe, and that the above
examples of an association between irradiation and breast cancer are due to the
unusually high levels of radiation (Perquin et al. 1976). However, there is some disagreement with this view. In particular, Upton et al. (1977) suggested that exposure to
1 rad would increase the risk of breast cancer by 1 per cent. Furthermore, Strax (1978)
suggested that if 40 million women were screened for 20 years, 120 would die from
radiation-induced breast cancer. However, since these concerns were raised, the dose
of radiation used in mammography has been reduced, although some concerns still
remain.
All tests are fallible and none can promise 100 per cent accuracy. Therefore, there is
always the chance of false positives and false negatives. A false-positive result may lead
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to unnecessary treatment interventions and the associated anxiety and uncertainty. A
false-negative result may lead to an illness remaining undetected, untreated and consequently progressing without medical intervention. In addition, a false-negative result
may lead to subsequent signs of illness (e.g. a breast lump, vaginal discharge) being
ignored by the patient.
Social harm Zola (1972) has argued that medicine is a means of social control and
suggested that there is a danger if individuals become too reliant on experts. In terms of
screening, monitoring and surveillance of populations could be seen as a forum for not
only examining individuals but controlling them. This argument is also made by Illich
(1974) in his book Medical Nemesis, where he argued that medicine is taking over the
responsibility for people’s health and creating a society of medical addicts. Screening
epitomizes this shift towards social control in that not only are the ill seen by the medical
profession but also the healthy as all individuals are now ‘at risk’ from illness (Armstrong
1995). Skrabanek (1988: 1155) argued that screening and the medicalization of health
‘serves as a justification for State intrusion into people’s private lives, and for stigmatising
those who do not conform’.
The possibility that screening may exacerbate existing stigma of particular social
groups is particularly relevant to the screening for genetic disorders. At present, society
is constituted of a variety of individuals, some of whom have genetic deficits such as
Down’s syndrome, cystic fibrosis and sickle-cell anaemia. Although these individuals
may be subjected to stereotyping and stigma, society provides treatment and support and
attempts to integrate them into the rest of the population. It is possible, however, that
screening for such disorders would lead to terminations of pregnancy and a reduction in
this stigmatized population. Although this would lead to fewer individuals with these
disorders (this may be a positive consequence, as no one wants to suffer from sickle-cell
anaemia) the individuals who are born with these problems may face increased stigma as
they would be part of a greatly reduced minority existing in a world with reduced social
provisions for support and treatment.
Autonomy – the patient has a right to choose
The third ethical principle is that of autonomy. This is based on the view that ‘mentally
competent and mature individuals should make decisions about their own future, subject
to the constraints required to ensure social order’ (Burke 1992). Proponents of screening
argue that screening is central to promoting autonomy in that the individual has a
right to have access to information about their health status. According to this model
of screening, the doctor is the patient’s gatekeeper to relevant information. However,
screening may also undermine an individual’s autonomy if it is construed as a form of
social control and doctors are seen as ‘lifestyle police’.
Justice – the equal distribution of resources
The fourth ethical principle of justice refers to the need for an equal distribution of
resources. This principle is relevant because screening programmes may be costly and
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