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Benjamin,
You are right that there are occasions where the interests of society have been considered more important than the rights of the individual. However the precedents that you cite differ from screening and illustrate why coercion is wrong in the German proposals.
(1) Vaccination. Refusal to be vaccinated does harm to others, not just oneself, in an uncontroversial (excluding flat earthers) and physical way.
(2) The cycle helmet example is, respectfully, not one of society versus individual interests but one of state paternalism: the state bans behaviour that is risky and for which prevention does no harm to the individual.
In the case of screening for cancer, the benefits to society are (in theory) economical: social insurance funds will (in theory) save money on paying out for expensive treatments later. BUT we do not ask people to pay more for their health care if they have contributed to their illness in other ways: smokers - ischaemic heart disease; the obese - type II diabetes care; alcoholics – liver disease; helmet wearing motorcyclists who drive recklessly and break several bones.
The ethical aspects of this also have a practical consequence for EBP. It is important that we are not associated with the misuse of evidence just because we place so much emphasis on on evidence.
Kev Hopayian
-------on 14/11/06 16:21, Djulbegovic, Benjamin at [log in to unmask] wrote:
As I was going through hundreds of e-mail accumulated in my in-box while I was away, I "discovered" this e-mail. I think that the issue is of crucial importance and having a further debate on this list may result in some important contributions to the future cases that are sure to come ( i.e. this issue will not go away). At the heart of the problem is the eternal question related to the interests of society vs. interests of individuals (as expressed via their preferences). While I am personally surprised by the list German officials selected (simply because evidence for net benefits for some of these interventions is shaky at best), it is Kev's reminder of the Sicily Statements that "….decisions [about health care] should be made by those receiving care…" that it is extremely thought-provoking. This is because most societies do override individual preferences and mandate the use of many health-care interventions when they judge that the interest of the group will be compromised if the interests of individuals prevail. To this effect, I can recall a couple of famous cases that were decided by the courts in favor of society ( e.g. right not to wear helmet when riding motorcycle, right to refuse smallpox vaccine etc). Please note that I am not arguing that the right of individuals should not be respected/taken into account- I am only trying to open the debate which needs further clarifications and a different framework…It looks to me that consideration of (quality of ) evidence should remain critical...perhaps, the use of popular framework "effective vs. preference-sensitive health care recommendations" could help reconcile the views….Would appreciate learning other folks' thoughts on the most optimal framework to address the questions sparked by German' authorities i.e. how should we go about reconciling interests of "society vs. individuals"?
Benjamin Djulbegovic, MD,PhD
Professor of Oncology and Medicine
H. Lee Moffitt Cancer Center & Research Institute at the University of South Florida Department of Interdisciplinary Oncology, MRC, Floor 2,Rm# 2067H
12902 Magnolia Drive
Tampa, FL 33612
[log in to unmask]" target="_blank">e-mail:[log in to unmask]
http://www.hsc.usf.edu/~bdjulbeg/ <http://www.hsc.usf.edu/~bdjulbeg/>
phone:(813)972-4673
fax:(813)745-6525
Subject: Re: Coercion in screening
Worrying - but there is a kind of logic to this even if the justification is not as strong as it could be. If preventive measures are going to be given greater importance then presumably the German government will wish to be fair in their dealings with all citizens. For instance, will they consider making payouts from the tax obtained from tobacco sales to those unfortunates who have developed lung cancer or other respiratory diseases as a result of smoking?
Ray Armstrong
Sent: Thursday, 2 November, 2006 8:34:23 AM
Subject: Coercion in screening
Legislation is being planned in Germany to coerce people, through financial
penalties, to take part in screening procedures. You can read the news story
at:
http://bmj.bmjjournals.com/cgi/data/333/7574/877-c/DC1/1
In brief, the following groups of people will have to make higher
co-payments if they do not take up screening and then develop the
associated cancer:
1 Women who have not had annual cervical smears from the age of 20
2. Women who have not had annual breast examinations from the age of 30 and
mammography every 2 years between the ages 50-69
3. Men who do not have annual digital rectal examination of the prostate
from the age of 45
4. All adults who do not participate in annual faecal occult blood testing
from the age of 55 and have two colonoscopies, ten years apart.
Does it matter to us who makes decisions about health care? I believe that
it does. The role of evidence in evidence-based health care is to INFORM
decisions. What "appears" to be true is not an immediate prescription for
what should be done. Practitioners and health service organisations should
guide but should not coerce. Coercion runs counter to the ethics of
evidence-based health care. As the Sicily Statement says:
"These decisions [about health care] should be made by those receiving care,
informed by the tacit and explicit knowledge of those providing care, within
the context of available resources."
The planned legislation also breaks with another ethical principle: the duty
to give information based on the best available evidence and a qualification
of the strength of that evidence. Many of the screening programmes above are
not backed up by sound evidence. Where evidence does exist, for example
mammography, interpretation of the evidence is controversial.
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