Margaret Somerville, founding director of the Centre for Medicine, Ethics and Law at McGill UniversityChristinne Muschi
Good facts are essential to good ethics. Taking the most up-to-date scientific evidence into account, the Canadian Task Force on Preventive Health Care has recommended abandoning or reducing the frequency of routine screenings for breast cancer on certain groups of women. Some people have strongly objected to these changes. Is this decision ethical?
First, the decision is made in conditions of some uncertainty. That's an ethically relevant fact. But, as André Picard, The Globe and Mail's public health reporter and columnist, points out: The scientific evidence that "early detection saves lives" is "equivocal," and the scientific evidence that the proposed changes are reasonably safe is "a lot more convincing than the dire warnings 'that thousands will die' " if screening is reduced. A common mistake is to reduce unavoidable uncertainty to false certainty and, as a result, make ethically wrong decisions. The task force seems to have tried to avoid this error. Those opposing their conclusions may not have.
Ethics requires non-malfeasance (first, do no harm) and beneficence (where possible, do good). Where harm is unavoidable, it must be clearly justified. As the debate over the changes in screening shows, we won't all agree on what constitutes good or harm, or justification for inflicting harms or risks, in any given circumstances.
The task force's goal is clearly to do more good than harm. But the benefits and harms of the changes in screening will not accrue to the same persons, which makes the situation more complex ethically. Those who would have benefited from finding their cancer earlier will be harmed; those who avoid false positives and unnecessary interventions, unfounded worry, and the costs screening involves, will be benefited.
Ethically, what should be the basic presumption on which decisions about routine screening are based? That choice can affect the decision outcome, because when we are in equal doubt as to the correct decision the basic presumption governs.
Under a "yes, but …" presumption, screening would be made available, but not if, for example, the woman had been screened within the past year. Under a "no, unless …" presumption, screening would not be available, unless, for example, the woman was in a high-risk group.
The person relying on the exception – the "unless" or the "but" – has the burden of proof of the exception. So in cases of equal doubt as to whether an exception applies, the woman will get screening under a "yes, but" presumption, but will be refused it, in exactly the same circumstances, under a "no, unless" presumption.
The task force has largely adopted a "no, unless" presumption. I note that this makes the frugal choice the default position.
The ethics that apply can differ at different levels of doing ethics: individual (micro); institutional (meso); societal (macro); and global (mega). And what is ethically required at institutional and societal levels can be in conflict with the individual level. For instance, efficiency and effectiveness in the use of health-care resources, such as screening, and justice in access to them, are ethical requirements for hospitals and governments, but physicians cannot put such considerations above the interests of their individual patients. They have a "primary obligation of personal care" to each patient and must put the patient's "best interests" first.
Decisions not to provide certain health-care resources to individuals that seem ethically acceptable at the individual level can also be very contentious ethically when blown up on the societal big screen, because they are seen as setting a precedent justifying "refusals of health care."
Cost-effectiveness assessments are necessary, but not solely determinative of ethical acceptability. Putting a price on life affects important shared values, in particular, the value that human life and money are not commensurable and we will pay whatever it costs to save or protect life. Consequently, as we see with the mammography recommendations, cost-saving is usually a secondary consideration. But increasingly, we will be faced with the question: Can we put a maximum price on health-care resources, without putting a price on life?
Features of the decision-making can also affect whether we see it as ethical. Hidden decision-making, hidden decision-makers, unidentified victims at the time of the decision, indirect impact of the decision on important values and so on, make us more likely to view it as acceptable. The opposite features make us more likely to view it as unacceptable.
Judging whether health-care decisions are ethical can be complex. Both the principles on which they're based and the reasons for them matter ethically, as do the processes used to make them.
In deciding on the rules that should govern access to interventions such as breast cancer screening, we also have responsibilities as individuals to use health-care resources ethically. We should take into account the "do something syndrome" – believing that doing something is better than doing nothing, which is not necessarily the case. We should recognize mistakes as to the causation of both beneficial and harmful outcomes, and in assuming that people in white coats always benefit us health-wise. And we should ask ourselves whether we are using health-care resources to seek control in order to reduce our anxiety, and are, in fact, just the "worried well."
Margaret Somerville is the founding director of the Centre for Medicine, Ethics and Law at McGill University.