BMJ summer column, here but cut and pasted till the login works below.
We are in serious trouble over screening. For all that medicine has cringed at paternalism and “doctor knows best,” has wrung its collective hands, and promised to do better, screening is still the last great preserve of unethical practice.
If you are about to have a small skin tag removed, a quick procedure with low risk of hazards and complications, you have to give your written consent. The doctor must explain the procedure and potential hazards; the patient must understand and agree before anything is done. You are an adult, properly informed by your personal doctor, and free to choose what to do.⇑
Compare that with screening tests. We are invited for cervical, breast, or bowel screening, with literature that aims to persuade us that the chance of screening saving our lives is high. The implication is that the tests are simple and that it is risky not to have them done. In Scotland, going for cervical screening is a process compared, in official NHS literature, with buying cinema tickets or booking a haircut. The leaflet “NHS breast screening” says that, “Screening can find cancers which are treated but which may not otherwise have been found during your lifetime,” but doesn’t say that this is the case with about one in four breast cancers, which are treated with mastectomy despite the likelihood of the disease behaving as though “benign.”
Patient literature for bowel cancer screening fails to mention the lack of improvement in overall mortality rates in the screened population. Meantime, health charities unhappy with the lack of national screening for prostate specific antigen advertise to men that the test is available and that doctors have no right to refuse it. For these screening tests there is no formal consent process; rather, appointments are prearranged or test kits are sent to people along with promotional literature. There is no cooling off period or a statutory discussion to ensure reasonable understanding of risks and benefits. There is no oversight by a medical practitioner to ensure that the individual person is making a decision in keeping with their desires. This is unethical because persuasion into screening is unethical. We have no right to assume that people wish to take part in a process which causes harm to a substantial proportion. We have no right to insist that because it may be good for some, it is good for all.
What should be done? Firstly, all adult screening programmes should be re-evaluated in the light of the most recent evidence by an independent body such as the National Institute for Health and Clinical Excellence. Secondly, information leaflets about screening should be provided by an independent body that does not care how many people are screened, just how many people are informed. And thirdly, doctors should withdraw support for screening programmes until fair and ethical information and free choices are made available to all.