Thursday, November 4, 2010

An amoral editorial on decision aids for screening in BMJ

The BMJ just published my rapid response to an editorial on decision aids for screening - such as bowel cancer screening.  I was surprised that the BMJ (the journal I would probably choose to have on a desert island if only allowed one journal) published an editorial that was blind to the ethical issues associated with public health screening. My response is pasted below or you can read it in the BMJ

The editorial is amoral. Neither immoral or moral, but written without any moral sensibility - in an ethics-free zone. The editorial suggests that a decision aid that improves decision making may be inappropriate because it lessens uptake among the better informed. But this is just fine. The editorial notes that faecal occult testing is evidence-based and since the objective of a screening program is to increase uptake it would be more appropriate to "structure the facts" to effect "a policy of informed uptake rather than informed decision making." Really? Surely informed decision making always trumps informed uptake from an ethical perspective?
This worrisome contention reflects a world view encapsulated in the paragraph that states:
"Decision aids are appropriate when there is insufficient evidence to indicate the best medical choice, patients' preferences are central to the choice, or the consequences of the options involve serious risks (or a combination of all three)."
In what situation are the patient's preferences NOT central to the choice of screening? We should recognise that a huge socio-cultural chasm sits between the general public and those who research and operate screening services - perhaps greater than the gap between different ethnic groups of the same educational and occupational background. Across that chasm there are huge differences in the manner in which risks are perceived and tolerated and in the valuing (and rumination on) present and future scenarios. Sometimes when we public health practitioners spend a lot of time at work we begin to envision a society that is structured in the image of our work. While health screening is elevated to a moral good for us, for the autonomous other it is just a lifestyle choice.

Competing interests: None declared

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