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.