Ethical economic, legal and social aspects of screening

(Please also see ethical, social and legal implications of a genetic screening test)

Public and media attention can lead to undue pressure on policy makers to introduce a screening programme without considering the opportunity costs and harms such as those from false results. For this reason, the ethical, economic and social consequences should always be carefully considered prior to the introduction of a new screening programme. In the UK these aspects are largely overseen by the UK National Screening Committee (UK NSC) (please also see section 3.7 on role of the UK NSC).

Ethical aspects

Beauchamp and Childress (2001) set out one of the most widely used frameworks in medical ethics. It consists of four principles, namely beneficence, non- maleficence, justice and autonomy. Screening programmes have the potential to violate each of these. In the worst case scenario a false negative test result can lead to preventable death.

Table 3.5.1 Ethical aspects of screening

Principle	Potential harm
Beneficence	All those screened are by definition symptom free but at some risk. Screening programmes may have large benefits at population level for those who can be offered early treatment but not every case will benefit
Non-malfeasance	Psychological harm from false positives in the interval before diagnostic testing Preventable death resulting from false-negative test Iatrogenic harm from the subsequent diagnostic test (which is often invasive) Unwarranted reassurance from false-negatives (may cause people to belittle symptoms that develop later)
Justice	Screening programmes should be used only when all other primary preventive measures are in place (because primary prevention is likely to be more cost-effective than screening) A challenge for screening programmes is to ensure equality in uptake and linkage into care pathways among deprived and affluent populations
Autonomy	Communicating risk to patients is notoriously difficult, and it is questionable whether people who partake in a screening programme truly understand the consequences of their participation (see informed choice section)

Economic aspects (Value for money)

Introducing and running a screening programme is expensive and associated with large numbers of people to be screened (including administrative costs) to find a small number of cases. The opportunity cost of the screening programme (including testing, diagnosis and treatment, administration, training and quality assurance) should be economically balanced in relation to expenditure on medical care as a whole. Economic evaluations should be subject to sensitivity analysis and discounting.

Legal aspects

Table 3.5.2 Legal aspects of screening

Test license and safety	The employed screening test needs to be licensed and safety approved by a statutory body
Qualification and Accreditation	To assure standards, diagnosticians involved in processing the test must be qualified, registered and accredited by a statutory body. To retain their accreditation, they must deal with a minimum number of abnormal cases each year
Confidentiality	Individual level information collected though screening must be kept confidential to authorized personnel only and managed in accordance with Caldecott Guidelines
The right NOT to be screened	For certain diagnoses (e.g. genetic screening for Huntington's disease), the right of children not to be screened may be protected in law. Likewise, the law offers protection to prisoners and to people with learning difficulties against coercion into screening programmes. The should be no discrimination of non-participants
Consent	Documentation of consent to be screened may be necessary in writing (see informed choice)

Social aspects

Health beliefs and attitudes are important influences in participation in screening, but may vary significantly between target population subgroups. These need be considered in the planning and monitoring stage in order to ensure that any new screening programme does not exacerbate health inequalities, e.g. between social classes or between different ethnic groups.

Table 3.5.3 Social aspects

Factors that may increase participation in screening	Factors that may decrease participation in screening
Knowledge of condition	Disease phobia
Perception of susceptibility	Stigma associated with condition
Perception of disease severity	Unpleasant diagnostic tests and treatment
Knowledge of availability of treatment	Socio-economic factors (e.g. income, education, deprivation, employment)
	Socio-demographic factors (age, sex, ethnicity, language, creed)
	Accessibility of screening sites

Reference materials

Principles of Biomedical Ethics, 5th edn. , Beauchamp T L, Childress J F. Oxford University Press, 2001
'Mastering Public Health: A postgraduate guide to examinations and revalidation. Lewis GH, Sheringham J, Kalim K, Crayford, TJB. London: Royal Society of Medicine Press Ltd; 2008