Truth-telling and preventive interventions

 

Recent articles in two different medical journals address an important concept in medical ethics as it pertains to screening tests: truth-telling.

The articles appeared in the New England Journal of Medicine (NEJM) and the Annals of Family Medicine (AFM). The NEJM article relates how, in the zeal to encourage people to have screening tests such as mammography for breast cancer and colonoscopy for colon cancer, “uninformative persuasion” is often employed, in which the benefits of having the test are extolled and the harms conveniently ignored. The truth behind the claims of benefit, however, is sometimes quite surprising. How effective would you estimate that mammography is at saving lives? It’s not as good as I guessed: mammography reduces a 50-year-old woman’s chance of dying from breast cancer by at best 25%. Another way to look at it: the chance of dying from breast cancer is reduced from 23 in 1000 to 19 in 1000. A reduction, yes, but not nearly as impressive as the hype would have it. Of course, it’s of paramount importance to the 4 in 1000 whose lives were saved. But wait, there’s more: for every breast cancer death prevented, three women are diagnosed with a cancer that they never would have known about because it would not have become apparent during their lifetime. Yet those women, as a result of their screening, go on to have unnecessary lumpectomies and mastectomies and radiation therapy (which can cause other cancers!) and all the emotional trauma that comes along with breast cancer treatment.

The AFM article describes the results of a study in which patients were asked to estimate the number of deaths and other events prevented by various interventions, including screening for breast and bowel cancer and using medications to prevent hip fractures and cardiovascular disease. Unsurprisingly, anywhere from 69 to 94% of participants overestimated the benefit of each intervention.

An accompanying editorial in the AFM discusses some of the reasons behind the widespread acceptance of these false beliefs. One reason is that they buttress the illusion that we are in control: “. . .false beliefs meet the psychological needs of patients for hope and safety, as well as for action, agency, and a sense of control.”  (The same holds true for physicians as well as patients.)

The fixed nature of these false beliefs means that anyone who tries to correct them is looked upon with suspicion. After all, it seems so right, so rational, so simple and safe to use preventive tests and medications to save lives. But the truth is not so simple, and the tests are not so safe. Modernity is all about control, and the hype behind these interventions panders directly to the control-mindset of modernity. But hype is lies, and lies cause harm. The duty to tell the truth is especially important in these instances when patients and their physicians must make potentially life-impacting decisions that have the potential for great harm as well as great good.

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Joe GibesJoel Goodnough, MD Recent comment authors
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Joel Goodnough, MD
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Joel Goodnough, MD

Truth telling sometimes has consequences for the physician. If the physician “discourages” a patient from getting preventative screening done and that patient goes on to get that cancer, what are the odds that the patient will remember the truth telling discussion accurately?