Education and debate

Professional and public attitudes towards unsolicited medical intervention

Matjaz Zwitter, radiation oncologist, ^a Tore Nilstun, moral philosopher, ^b Lisbeth E Knudsen, genetic toxicologist, ^c Branko Zakotnik, medical oncologist, ^a Johann Klocker, medical oncologist, ^d Stefan Bremberg, general practitioner, ^b Gerda Frentz, dermatologist, ^e Ursula Klocker-Kaiser, psychiatrist, ^f Jette Pedersen, project coordinator. ^e

^a Institute of Oncology, Zaloska 2, 1001 Ljubljana, Slovenia, ^b Department of Medical Ethics, Lund University, SE-222 22 Lund, Sweden, ^c National Institute of Occupational Health, DK 2100 Copenhagen O, Denmark, ^d Oncological Institute, 1st Medical Department, General Hospital, A-9026 Klagenfurt, Austria, ^e Institute of Preventive Medicine, Copenhagen Municipal Hospital, DK 1399 Copenhagen C, ^f Centre of Mental Health, General Hospital, Klagenfurt

Correspondence to: Dr Zwitter mzwitter{at}onko-i.si

Several studies have investigated medical intervention in common aspects of lifestyle, and the subject has been discussed from a legal, ethical, and practical point of view.¹ Fluoridation of water supplies, legal enforcement of safety measures such as compulsory wearing of seat belts or helmets, and restriction of unhealthy habits such as drinking alcohol or smoking are typical examples of paternalistic programmesactions that aim to prevent harm or promote the good of others, irrespective of the individual's own wishes. ^{2 3} What is the position, however, when a doctor's action is neither solicited nor part of his or her contractual duties? In such a situationwhich we define as unsolicited medical interventionthe doctor can only speculate about whether his or her action will be welcomed and hence understood as an act of beneficence or whether it will be regarded as an unjustified paternalistic intrusion into privacy.⁴

According to the 1949 international code of medical ethics of the World Medical Association⁵ and to legislation in many different countries, doctors are obliged to offer first aid in an emergency. However, apart from this relatively clear situation, dilemmas in relation to unsolicited medical intervention have rarely been discussed. The European Code of Medical Ethics, issued in Paris in January 1987 by representatives of the medical associations of the European Community, emphasises the principle that "doctors can only use professional knowledge to improve and maintain the health of those who put themselves in their care."⁵

We aimed to assess the attitudes of doctors and the expectations of the lay public to unsolicited medical intervention by asking them to consider the ethics of unsolicited medical intervention in three scenarios. We believed that a comparison of the responses of doctors, subgroups of doctors, and lay people would help us to identify gaps between expectations and reality.

	Survey of attitudes

A survey was undertaken in four European countriesAustria, Denmark, Slovenia, and Sweden. In each location, an explanatory letter, a questionnaire, and a stamped addressed envelope were mailed or handed out personally to doctors and to lay people. No further explanations or help were provided in answering the questions, and strict anonymity was assured. No reminders were sent to those who did not respond.

Doctors
Doctors were chosen at random from the membership list of a particular section of a medical society, medical practice, or another similar association. Altogether, 845 doctors were contacted and 583 returned the questionnaire (response rate 69.0%). The four groups of doctors included in the survey were general practitioners (166 respondents), surgeons and gynaecologists (186), radiation oncologists or medical oncologists (114), and doctors working in laboratory medicine or epidemiology who had no direct contact with patients (111). The specialty of six doctors who responded is unknown.

Lay people
Adults were approached on urban streets and asked to participate. Saturday morning was the preferred time, as overrepresentation of unemployed people might have occurred if approaches had been made on weekdays. Altogether 569 of the 1096 people (51.9%) who were contacted responded.

Scenarios
Three scenarios describing unsolicited medical intervention were prepared (box). The same scenarios, with minor modifications in wording, were presented to the doctors and lay people. The question for the doctors was whether or not they would intervene. For the lay people, the question was whether or not (in their opinion) the doctor should intervene in such a situation.

	People's responses

Traffic accident
Altogether 96.2% of doctors who responded (561/583) said that they would intervene, and even more lay people (97.9%; 557/569) believed that the doctor should help in such a situation. Although the number of those who did not favour intervention was small, the difference between the two groups was significant (P=0.02). Surgeons were more inclined to intervene than other doctors (182/186, 98%, compared with 373/396, 95%; P=0.06). Neither sex nor age influenced the respondent's preferences. Across the four countries, 95.3% to 99.6% of all replies favoured intervention. Danish respondents were significantly less likely to support intervention than respondents in the other three countries (P=0.002).

Suspicion of melanoma
Only 23.3% (136/583) of the doctors but 34.4% (196/569) of the lay people would have addressed a stranger in such a situation (P<0.001). General practitioners (19%, (32/166), of positive replies) and surgeons (18%, 34/186) were significantly less in favour of intervention than oncologists (34%, 39/114) or doctors without direct contact with patients (27%, 30/111; P=0.01). Sex and age had no influence on the attitudes of the respondents. Significant differences were seen between countries47% (98/209) of Austrian respondents but only 21.5% (148/687) of Danish respondents agreed with intervention (P<0.001).

Genetic predisposition to breast cancer
Only 39.5% (230/583) of doctors but 62.6% (356/569) of lay people favoured contacting the carrier of a breast cancer gene (P<0.001). The specialty of the doctors had no influence on their response. Nor were responses influenced by sex or age. Respondents from Austria were again most inclined (79%, 164/209) and those from Sweden least inclined to intervene (39%, 64/156; P<0.001).

	Discussion

In all the situations presented, both intervention and non-intervention have ethical benefits and costs for some of those involved. Our identification of these benefits and costs is based on the principles of respect for autonomy, non-maleficence, and beneficence. ^{6 7}

The benefits of intervention by the doctor in the scenarios described are as follows: direct help to someone who has probably been injured in a traffic accident; the possibility of earlier consultation and perhaps better prognosis for a person with a suspected melanoma; and knowledge of a long term health risk for a young woman with a predisposition for breast cancer that may lead to better chances of early detection and more successful treatment. In the language of medical ethics, intervention by a doctor could be described as an act of beneficence to all three persons. Intervention in the second and the third scenarios might also be understood as promoting autonomythat is, increasing the options of the women so that they could make an informed choice.

However, intervention by the doctor is also associated with ethical costs. In the first scenario, the doctor would have to change his plans and break a promise to his daughter. The ethical cost of intervention in the second scenario is invasion of privacy. The woman concerned might also find it embarrassing to discuss her "black spot" on the bus. The woman is certainly aware of the lesion on her face; she has probably seen a doctor already or she may have refused treatment no matter what the nature of the black spot.⁸ In the third scenario, the most obvious ethical cost of intervention is a lifelong emotional burden for a young woman told that she has a hereditary predisposition to cancer at an age when any medical action would be premature.^9-11

In the past, doctors have strived to convince lay people of the importance of public health measures such as proper sanitation, vaccination programmes, or a healthy lifestyle. The doctors of today and tomorrow face a different challengethe public has high expectations of prevention, early detection, and treatment of diseases; disease or death are not regarded as natural events; and a poor outcome is often attributed to a medical omission or mistake rather than the natural course of a disease. In such an environment, important health policy decisions, such as breast cancer screening programmes in young women, are made for political rather than medical reasons.¹² We conclude that doctors nowadays feel a need to resist rather than support a trend towards the increased invasion of medicine into everyday life.

	Acknowledgments

MZ, TN, and LEK thank Dr Kirsi Vahakangas for inviting them to the International Meeting on Molecular Epidemiology and Ethics in Oulu, Finland, where they discussed the idea for this survey.

Competing interests: None declared.

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(Accepted 14 August 1998)