Risk, Overdiagnosis and Ethical Justifications

Is the Cure Worse than the Disease? The Ethics of Imposing Risk in Public Health

Efforts to improve public health, both in the context of infectious diseases and non-communicable diseases, will often consist of measures that confer risk on some persons to bring about benefits to those same people or others. Still, it is unclear what exactly justifies implementing such measures that impose risk on some people and not others in the context of public health. Herein, we build on existing autonomy-based accounts of ethical risk imposition by arguing that considerations of imposing risk in public health should be centered on a relational autonomy and relational justice approach. Doing so better captures what makes some risk permissible and others not by exploring the importance of power and context in such deliberations. We conclude the paper by applying a relational account of risk imposition in the cases of (a) COVID-19 measures and (b) the regulation of sugar-sweetened beverages to illustrate its explanatory power.

Breast Cancer in Asia: Incidence, Mortality, Early Detection, Mammography Programs, and Risk-Based Screening Initiatives

Simple Summary

Nearly all breast cancer patients survive for more than five years when the tumor is found early and in the localized stage. Regular clinical breast examinations, mammograms, and monthly self-exams of the breasts all contribute to early detection. However, late-stage breast cancers are common in many Asian countries. Low-income countries suffer from a lack of resources for breast cancer screening. High-income countries, on the other hand, are not benefiting fully from national breast screening programs due to an underutilization of the preventive healthcare services available. Existing reviews on Asian breast cancers are heavily focused on risk factors. The question of whether we should adopt or adapt the knowledge generated from non-Asian breast cancers would benefit from an extension into screening guidelines. In addition, several Asian countries are piloting studies that move away from the age-based screening paradigm.

Abstract

Close to half (45.4%) of the 2.3 million breast cancers (BC) diagnosed in 2020 were from Asia. While the burden of breast cancer has been examined at the level of broad geographic regions, literature on more in-depth coverage of the individual countries and subregions of the Asian continent is lacking. This narrative review examines the breast cancer burden in 47 Asian countries. Breast cancer screening guidelines and risk-based screening initiatives are discussed.

Screening is not always healthy: an ethical analysis of health screening packages in Singapore

Background

Health screening is undertaken to identify individuals who are deemed at higher risk of disease for further diagnostic testing so that they may possibly benefit from interventions to modify the natural course of disease. In Singapore, screening tests are widely available in the form of a package, which bundles multiple tests in one session and commonly includes non-recommended tests. There are various ethical issues associated with such testing as they may not be clinically appropriate and can result in more harm than benefit. This article describes the practice of health screening packages, identifies the ethical issues arising from such packages and discusses the implications of these ethical issues on policy and practice of screening in Singapore.

Methods

A content analysis of the websites of providers offering general health screening packages to individuals was conducted. A total of 14 health screening package providers were analysed for how packages were conducted and promoted, how clinically appropriate screening tests were, and the price range and composition of screening packages. A normative ethical analysis based on the four principles approach of beneficence, non-maleficence, autonomy and justice in biomedical ethics was used.

Results

Twelve of the 14 providers included non-recommended tests such as tumour markers, treadmill stress tests and MRI scans in their general health screening packages. Package prices ranged from S$26 to S$10,561, with providers charging higher when more tests were included. Health screening packages were broadly conducted in three stages: (1) the offer and selection of a health screening package; (2) medical assessment and performance of screening tests; (3) a post-screening review. While material provided by all providers was factual, there was no information on the potential risks or harms of screening.

Conclusion

Several ethical issues were identified that should be addressed with regard to health screening packages in Singapore. A key issue was the information gap between providers and patients, which may result in patients undergoing inappropriate testing that may be more harmful than beneficial. Health screening packages can stimulate unnecessary demand for healthcare and contribute to an inequitable distribution of healthcare resources.

Breast cancer risk stratification for mammographic screening: A nation-wide screening cohort of 24,431 women in Singapore

Background

Breast cancer incidence is increasing in Asia. However, few women in Singapore attend routine mammography screening. We aim to identify women at high risk of breast cancer who will benefit most from regular screening using the Gail model and information from their first screen (recall status and mammographic density).

Methods

In 24,431 Asian women (50–69 years) who attended screening between 1994 and 1997, 117 developed breast cancer within 5 years of screening. Cox proportional hazard models were used to study the associations between risk classifiers (Gail model 5‐year absolute risk, recall status, mammographic density), and breast cancer occurrence. The efficacy of risk stratification was evaluated by considering sensitivity, specificity, and the proportion of cancers identified.

Results

Adjusting for information from first screen attenuated the hazard ratios (HR) associated with 5‐year absolute risk (continuous, unadjusted HR [95% confidence interval]: 2.3 [1.8–3.1], adjusted HR: 1.9 [1.4–2.6]), but improved the discriminatory ability of the model (unadjusted AUC: 0.615 [0.559–0.670], adjusted AUC: 0.703 [0.653–0.753]). The sensitivity and specificity of the adjusted model were 0.709 and 0.622, respectively. Thirty‐eight percent of all breast cancers were detected in 12% of the study population considered high risk (top five percentile of the Gail model 5‐year absolute risk [absolute risk ≥1.43%], were recalled, and/or mammographic density ≥50%).

Conclusion

The Gail model is able to stratify women based on their individual breast cancer risk in this population. Including information from the first screen can improve prediction in the 5 years after screening. Risk stratification has the potential to pick up more cancers.

Mapping out the philosophical questions of AI and clinical practice in diagnosing and treating mental disorders

How to classify the human condition? This is one of the main problems psychiatry has struggled with since the first diagnostic systems. The furore over the recent editions of the diagnostic systems DSM-5 and ICD-11 has evidenced it to still pose a wicked problem. Recent advances in techniques and methods of artificial intelligence and computing power which allows for the analysis of large data sets have been proposed as a possible solution for this and other problems in classification, diagnosing, and treating mental disorders. However, mental disorders contain some specific inherent features, which require critical consideration and analysis. The promises of AI for mental disorders are threatened by the unmeasurable aspects of mental disorders, and for this reason the use of AI may lead to ethically and practically undesirable consequences in its effective processing. We consider such novel and unique questions AI presents for mental health disorders in detail and evaluate potential novel, AI-specific, ethical implications.

Navigating a world of genes: A conceptual analysis of gene fetishism, geneticization, genetic exceptionalism and genetic essentialism

Genetics, as a discipline, is an essential part of the modern world. However, analyzing the interaction between genetics and society can be complex. Therefore, terminology has arisen from diverse fields to better understand genetics and its relation to other domains. Nevertheless, the diverse origins of many of these terms, as well as a lack of clarity in their definitions, have led to differences in use. This paper focuses on four such terms: genetic fetishism, geneticization, genetic essentialism, and genetic exceptionalism. By clarifying what each term means, the fields that utilize them will be helped. Furthermore, these terms can have specific value to bioethics in analyzing ethical issues that arise from genetics and the interaction with the socio-cultural world. While these terms may not always be applicable, a more careful analysis of their meaning can cultivate a more scientific and rigorous analysis of the ways genetics impacts and is understood by humanity.

Why Does Cancer Screening Persist Despite the Potential to Harm?

Population screening for early-stage cancer or cancer precursors began in the mid-twentieth century, with the goal of reducing suffering from cancer illness and lengthening average life by preventing cancer deaths. Since the establishment of cancer screening, concerns have emerged that it may be doing considerable harm; despite this, screening practices have remained relatively intractable. This intractability in the face of harm is the central problematic of my analysis. I reinterpret a large study of breast, cervical and prostate cancer screening completed recently by our Australian research group, working across empirical bioethics, public health and social science. I suggest three reasons why cancer screening might persist as it does, and thus reach conclusions about what might be required to make cancer screening systems more responsive to the potential for harm.