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Should Health Screening be Private?

BMJ 1999; 318 doi: (Published 29 May 1999) Cite this as: BMJ 1999;318:1494
  1. John Cairns, director
  1. Health Economics Research Unit, University of Aberdeen

    Jim Thornton

    Institute of Economic Affairs, £5.60, pp 78

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    ISBN 0255364512

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    The NHS should stop screening for breast and cervical cancer. Indeed, the NHS should offer screening only in very limited circumstances, such as for adults only when the screening is of undisputed cost effectiveness and these adults could not otherwise afford it. Jim Thornton reaches these controversial conclusions largely because of his belief that consumers are the only people able to judge whether the benefits of screening outweigh the potential side effects. One consequence is that it is generally impossible to measure the ratio of costs to benefits of any screening programme.

    This view of consumers raises several problems. There must be considerable doubt as to whether consumers have sufficient information to judge consistently what is in their best interests. In addition, although pregnant women would be deemed the best judges of their own welfare, they would not be considered the best judges of their babies' welfare. Children should be protected from lazy and incompetent parents, but such people should not be protected from themselves. Thornton believes that publicly provided screening is coercive in nature and that, by implication, consumers will be screened when it may not be in their interests. But if consumers are the best judges will they not make the correct decision? There are also likely to be major practical difficulties distinguishing between someone unable to afford screening and someone choosing not to pay for screening because the benefits of screening are less than the benefits they would have to forego to pay for the screening.

    It is not clear whether Thornton would extend his reasoning to other forms of health care or whether he regards screening as somehow special. Should the NHS as a whole provide care only for adults who cannot afford to pay for their own? One of the principles on which the NHS is based is that health care should be provided free at the time of use. This principle commands wide support, possibly because people feel better off living in a society where this holds true. If this is the case, the benefits of health care in general, and of screening in particular, are not purely private as Thornton claims.

    Screening potentially affects most if not all of the population, and so a discussion of how it should be provided is of considerable potential interest. Readers of this essay will be encouraged to think a bit more about why they hold the views that they do, but I suspect that it will not lead to any changes in those views.

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