Risk, Overdiagnosis and Ethical Justifications

Wendy A Rogers,Vikki A Entwistle,Stacy M Carter

doi:10.1007/s10728-019-00369-7

Abstract

Many healthcare practices expose people to risks of harmful outcomes. However, the major theories of moral philosophy struggle to assess whether, when and why it is ethically justifiable to expose individuals to risks, as opposed to actually harming them. Sven Ove Hansson has proposed an approach to the ethical assessment of risk imposition that encourages attention to factors including questions of justice in the distribution of advantage and risk, people’s acceptance or otherwise of risks, and the scope individuals have to influence the practices that generate risk. This paper investigates the ethical justifiability of preventive healthcare practices that expose people to risks including overdiagnosis. We applied Hansson’s framework to three such practices: an ‘ideal’ breast screening service, a commercial personal genome testing service, and a guideline that lowers the diagnostic threshold for hypertension. The framework was challenging to apply, not least because healthcare has unclear boundaries and involves highly complex practices. Nonetheless, the framework encouraged attention to issues that would be widely recognised as morally pertinent. Our assessment supports the view that at least some preventive healthcare practices that impose risks including that of overdiagnosis are not ethically justifiable. Further work is however needed to develop and/or test refined assessment criteria and guidance for applying them.

Highlights

In traditional Russian roulette, a player (P) voluntarily exposes her or himself to a one in six possibility of inflicting a lethal wound when pulling the trigger.1 What‐ ever we might think about this as a pastime, P does not seem to be wronged
This example points to the challenge of morally appraising risk: if it is wrong to harm V, to what extent is it wrong to impose the possibility of that same harm to V? [1] If the gun had 1000 cham‐ bers and only one bullet, would P be less wrong in playing Russian roulette with V? According to various scholars, while moral philosophy relies extensively on the idea of harming as a wrong, prevailing normative theories have trouble explaining when and why it is wrong to impose risk in which potential harms are not inevitable or certain [1, 12, 13, 26]
In “Overdiagnosis” section, we examine the risks of ODx and associated harms as generated by some preventive healthcare prac‐ tices, but before the section “Hansson’s criteria for the ethical acceptability of

Summary

Introduction

In traditional Russian roulette, a player (P) voluntarily exposes her or himself to a one in six possibility of inflicting a lethal wound when pulling the trigger.1 What‐ ever we might think about this as a pastime, P does not seem to be wronged. We use Hansson’s approach to consider the ethical acceptability of preventive healthcare practices that impose risks associated with overdiagnosis.

Results

Conclusion