Is opportunistic disease prevention in the consultation ethically justifiable?

doi:10.1136/bmj.327.7413.498

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Linn Getz, occupational physician (linngetz@med.is)1,
Johann A Sigurdsson, professor in family medicine2,
Irene Hetlevik, associate professor in general practice3

¹Office of Human Resources, Landspitali University Hospital, IS-101 Reykjavík, Iceland
²Department of Family Medicine, University of Iceland, Solvangur Health Centre, IS-220 Hafnarfjördur, Iceland
³Department of General Practice and Community Medicine, Norwegian University of Science and Technology, N-7489 Trondheim, Norway Irene Hetlevik

Correspondence to: L Getz

Accepted 5 June 2003

Medical resources are increasingly shifting from making patients better to preventing them from becoming ill. Genetic testing is likely to extend the list of conditions that can be screened for.Is it time to stop and consider whom we screen and how we approach it

Most medical experts and health authorities consider consultations in primary health care ideal for opportunistic health promotion and disease prevention. Doctors are thus expected to discuss preventive measures even when they are not among the reasons for contact. But are such opportunistic initiatives ethically justifiable in contemporary Western medicine? We argue that doctors should maintain a clear focus on each patient's reasons for seeking help rather than be distracted by an increasing list of standardised preventive measures with unpredictable relevance to the individual.

Aims of a good consultation

The cornerstone of medical practice is the consultation between a patient who seeks help and a doctor whomthe person trusts.1 Several theoretical models have been developed to analyse and improve the quality of the consultation. In 1979, Stott and Davis presented an influential model that elicited four potentials of the encounter between patient and doctor: management of presenting problems, modification of help seeking behaviour, management of continuing problems, and opportunistic health promotion.2 Since then, opportunistic preventive initiatives have become considered to be part of good medical practice.

From a moral point of view, preventive medicine– that is, initiatives to improve health among people who are currently free of symptoms–is fundamentally different from curative medicine, which is offered to patientswho seek medical help. The two disciplines imply different promises and have different obligations to the individuals whose lives they modify.3

Expanding agenda of risk and prevention

When Stott and Davis developed their model, the number of relevant opportunistic initiatives was limited and seemed both technically feasible and ethically justifiable. However, interest in risk factors in healthy …