CANCER SCREENING: A PUBLIC HEALTH INTERVENTION BASED ON COLLECTIVE ETHIC

Abstract

Cancer screening is a public health intervention targeting
population in which more than 90% of the people have
not the disease. The objective of such intervention is a
collective one: to decrease the cancer mortality rate of this
population, identifying by a test the apparently healthy
people who already are developing such a disease, but
without creating any injury to the whole population. The
individual benefit cannot be established with certitude.
Consequently screening is based on collective ethical rules
which are different from those used in the field of curative
medicine based on the single relation “doctor-patient”. The
finality of public health are guided by ethical values such
as beneficence and no malfeasance, justice and autonomy,
solidarity and universality.
Within such a setting the responsibility of the policy makers
is engaged since it is their own duty to initiate investigations on people who are not asking for. The ethical rules to
organize such screening program were proposed by Wilson
and Jünker to the WHO and are applicable to all countries.
Besides the necessity to lay on its evidence based efficacy,
the decision to implement a cancer screening program, is
also dependent, in each country, of the analysis of, at least,
the following 5 point:
1. Which types of cancer are relevant for screening and for
which population (gender, age…)?
2. What human and material means are needed to maximize benefit and to reduce risks for the targeted population,
and avoiding inequalities?
3. Are the health system and health costs adapted to such
program which needs to be economically acceptable within
the global health budget?
4. How to secure that adequate information is given to
the various socio-cultural groups and to guarantee for each
person the autonomy of their decision to participate. In
such a context of uncertainty concerning the individual benefit, the challenge of loyal, relevant, trustworthy and
complete information is put down.
5. Which evaluation process and which modification
procedures of the program can be established? The data
to evaluate the balance benefit/risk are only known and
monitored in organized screening. Furthermore the balance
risk/efficiency has to be estimated regularly because it is
moving with new medical knowledge and with epidemiological modifications; consequently that must conduct to a
regular interrogation on the running screening programs
and to adapt the screening programs to such time trends.