The University Record, November 12, 1997
From Medical Center Public Relations
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. David J. Doukas, associate professor in the Department of Family Medicine and director for clinical bioethics in the Program in Society and Medicine, 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 authors say that there is considerable disagreement in the medical community over the routine use of mammograms in women under age 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 authors describes several potential risks of screening tests with controversial benefits, including:
Physicians have a responsibility to inform patients of the limitations and risks of screening tests, the authors maintain, 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 proved 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."
Doukas is the lead author of the article. Co-authors are Michael Fetters and Mack Ruffin IV, both from the Department of Family Medicine, and Laurence B. McCullough of Baylor Medical College.