ANN ARBOR---Doctors can face an ethical dilemma when patients request screening tests---such as those for breast cancer and prostate cancer---that may be ill-advised under certain circumstances. A University of Michigan physician and three co-authors explore that predicament in the article "Ethical Considerations in the Provision of Controversial Screening Tests," in the current issue of the Archives of Family Medicine.
Physicians may face this quandary when patients claim entitlement to such tests under their insurance plans, when health advocacy and professional groups recommend their use, or when media attention heightens interest in the latest screening breakthrough, the article notes.
These claims, however, may not be supported by scientific evidence demonstrating that the screening tests meet a minimum criteria of effectiveness.
For example, the article points out that there is considerable disagreement in the medical community over the routine use of mammograms in women under the age of 50 and prostate specific antigen tests in men. The ethical issue becomes more complicated when doctors provide controversial screening tests because they fear a future lawsuit by a patient who later develops a disease.
The article describes several potential risks of screening tests with controversial benefits, including:
- Reliance on screening tests before their effectiveness has been corroborated by adequate research.
- Creating the impression that such exams can reduce a patient's risk to zero---possibly leading them to make uninformed medical decisions.
- Inaccurate, false positive results which can cause profound anxiety and require additional testing that can be increasingly invasive and costly.
- Depleting society's limited medical resources.
The article asserts that physicians have a responsibility to inform patients of the limitations and risks of screening tests---and to refuse to order tests that would violate their medical and ethical judgment. Physicians can counsel patients about the lack of scientific evidence regarding a test's benefits and the fact that no test can assure zero-risk of disease.
Physicians also may choose to administer a test if initial scientific evidence supports a claim of benefit and the patient is aware of the risks. Alternatively, the physician has the option to refuse to provide the test, or refer the patient to another doctor who will provide it.
This education and negotiation process is intended to apprise the patient about which screening tests have been proven to be beneficial and which have not. Such a discussion can result in patients making informed and learned health care decisions. "For most diseases for which there is a potential screening test, the effectiveness of screening is controversial," the article says. "Physicians can use a 'preventive ethics' approach to explain that tests with controversial benefits are unlikely to be helpful."
The lead author, David J. Doukas, M.D., is an associate professor in the U-M Department of Family Practice and associate director for clinical bioethics in the U-M Program in Society and Medicine. Co-authors are Michael Fetters, M.D., and Mack Ruffin IV, M.D., both from the U-M Department of Family Medicine, and Laurence B. McCullough, Ph.D., of Baylor Medical College.