ETHICAL ISSUES IN CERVICAL SCREENING

This paper will provide an overview on current ethical dilemmas in cervical screening. Screening has led to very significant reductions in mortality from this disease. Yet it requires a major commitment from a wide range of health professionals and health sectors including pathology, primary care, public health and NHS cancer screening services. Despite its very significant achievements, cervical screening can be associated with adverse events and in contemporary cancer screening programmes, there is a need to provide patients with a balanced view on the benefits of participating. The following areas will be covered: (1) Social inequalities: does cervical screening reinforce health and social inequalities, is it sufficiently available to lower socio‐economic groups and does it target the appropriate sub‐groups within the population? (2) Informed choice: there is a change in focus in cancer screening programmes – until recently most effort has focused on promoting uptake. Informed choice is now seen as a worthy objective of screening programmes. GP practices have, in the past, been accused of overly coercive tactics in achieving their target rates for cervical screening. This has the potential to cause significant harm through such efforts. Ideally we want participants in cancer screening to have a very clear idea of both the risks and benefits of participation, yet this can involve a potentially lengthy process of information sharing between health care providers and invitees. How do we achieve an appropriate balance between informed choice and adequate levels of uptake? (3) Opportunity costs of cervical screening: Screening is an expensive process, the health service is stretched and there is a significant opportunity cost. Should we be diverting resource to other diseases of higher prevalence and greater public health burden? (4) When cervical screening goes wrong: what can we learn from instances in the past where QA systems and other aspects of cervical screening have failed and patients have been caused harm? (5) New challenges posed by HPV testing and vaccination. (6) Future directions. Where should cervical screening be heading, what will the future ethical challenges be? The intention of the paper is to summarise current evidence and issues, and to prompt discussion on ways that health professionals, in conjunction with consumer groups, can move forward on these and other important ethical issues.