Is opportunistic disease prevention in the consultation ethically justifiable?
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7413.498 (Published 28 August 2003) Cite this as: BMJ 2003;327:498All rapid responses
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EDITOR- Questioning the justification for opportunistic disease
prevention in the primary care consultation because of a hugely expanded
agenda of risk and prevention since 1979 is the position of Getz et al
(1). This is no more logical than the questioning of clinical
investigation of patients by general practitioners because of the steep
rise in the number of available tests in the past 25 years. In both
situations the correct clinical course is to follow good science and sound
professional discipline so as to be selective in the interests of patient
well being and careful use of resources.
Getz and colleagues rightly highlight the importance of caution in
imposing on patients the rapidly expanding range of screening tests/risk
factors in the absence of sufficient time (or skill or evidence) to ensure
that fully informed consent can be obtained(1). However this differs from
a wholesale retreat from the broad approach to consultations that has been
internationally accepted as reflecting quality in general practice
consultations. Each patient needs a clinical generalist who maintains a
broad view of his or her personal care health needs and who is not just
focussed on the immediate issue to the detriment of anticipatory care in
chronic disease and health promotion (2). The fact that some patients want
their doctors to limit themselves to presenting problems is not new and
neither is the evidence for caution over how and when to raise these wider
concerns (2,3,4,5).
A lot of useful research has been conducted in this area since 1979
but one continuing source of confusion lies between screening and
lifestyle interventions that are appropriate for individual risk reduction
and those that are only likely to provide benefit at population level.
Many genetic tests are not acceptable to some patients when they are fully
informed of the consequences of the tests. Even the management of
hypertension, which has a reasonable chance of benefitting the individual,
is sometimes not accepted when the absolute risk/benefit balance is
understood by the patient. In contrast immunization is an example where
herd immunity is critical to protection of the individual and there may be
a case for government to make population decisions rather than expect the
individual to weigh the risks.
General practitioners and their teams will develop much more
sophisticated ways to help patients grapple with choices in the future. It
would be wholly unethical to reduce their responsibility in this area.
Sometimes help will come from technology or other professionals in the
team, but clinical generalists cannot eschew overall responsibility for
the process and its research base.
1) Getz J Sigurdsson A, Hetlevik I. Is opportunistic disease
prevention in the consultation ethically justifiable? BMJ 2002; 327: 498-
500.
2) RCGP The Nature of General Practice. Report from General Practice No
27. RCGP 1996.
3) Stott NCH Primary Health Care. Springer Verlag 1983.
4)Stott NCH, Pill RM. 'Advise yes, Dictate no': patients views on health
promotion in the consultation. Family Practice 1990; 7: 125-131.
Competing interests:
None declared
Competing interests: No competing interests
Your article under Education and Debate is timely.
In New Zealand, as in many western countries, we are being exhorted
without respite to consider population health targets, particularly those
that have easily countable outcomes, and to identify all biomedical risks
in our general practice populations. Some "lifestyle" issues are also now
bone fide to enquire about (and tick off, and recall to re-ask
about)including smoking and alcohol consumption and gambling habits. It
possible to argue that they have no significance for some individuals -
but the balance between the personal and the public benefit is sometimes
difficult to find!
More recently the NZ Ministry of Health has recommended screening for
partner abuse in acknowledgment of the considerable health consequences of
relationships that are characterised by ongoing patterns that leave
partners fearful, degraded and dispirited, not to mention physically
damaged and tragically in some instances, dead. The psychological and
biomedical consequences are far reaching, and a fraction of the money
spent treating outcomes placed in the "ask about it" basket will surely
reap rewards in future - both for partners and thier children.
Paying attention to the "relational" aspects of the patients in front of
us is an intensely personal part of health care - yet also part of
population screening - indeed perhaps one of the pivots on which public
and private health hinge.
Making the judgement on the timing and appropriateness of ensuring these
issues are regularly covered requires training and - in the beginning at
least - a certain amount of courage - but a gathering number of anecdotal
outcomes from practitioners who are working on smoking, gambling addiction
and obesity as well as partner abuse areas, gives one the hope that
outcome studies from all these areas will be done to show something
"countable" for publication - like reduced antihypertensive requirements,
less money spent on antidepressant medication, reduced gastro-intestinal
symptoms, reduced suicide rates... "population" statistics that are
personal in their effects.
Fitting the relevant "preventive" questions to the patient in front of us
at the right moment is the trick - ah Wisdom - better than rubies!
(Apologies to Proverbs 9:1)
Competing interests:
Trainer in Recognition and Response to Partner Abuse in General Practice
Competing interests: No competing interests
creep of medical surveillance
There is not enough attention being paid to the moral question of
using what is often covert surveillance by some GPs. Many people are
surprised to find GPs taking such an interest in their private lives. Most
do not know it is happening. Some are interested in the area of abuse or
relationships for psychological reasons of their own, have
colleagues/relatives/friends who are working specifically in the field and
with whom they are sharing private information without going though proper
procedures, which hold them accountable to managers and to those who
consult them. It is interesting how many more cases seem to crop up where
there is a personal interst, whereas fewer cases are brought to light in
areas where GPs have no such focus.
If medical surveillance is to expand in
the way some GPs wish, the public has a right to know and to agree. Where
some GPs are publishing books for private sale as well as carrying out
research, those who consult them have a right to know they are using
material from what are supposed to be confidential meetings - whether
these are anonymised or not. It is rarely that there is a need for covert
surveillance. Any intrusion into private lives is a sensitive business.
Many adults and children have been dealing with difficult situations for
many years; they have complex psychological reasons for attemting to heal
aspects of relationships, are often deeply compassionate, highly
thoughtful, have a sophisticated understanding of complex issues, have
historical knowledge of causes and have a grasp of subtle aspects which
are often inexplicable to others. When GPs or others jump
in heavy footed and attempt to appropriate others' lives it can do much
irreparable damage. Obviously horrendous cases of abuse colour perception
but they are rare and should not be used as an excuse for some GPs to
carry out covert resarch and surveillance of those who consult them. Who
is monitoring their private lives? Surely the days of the 'flaneurs' of
Victorian days are not going to be revived now?
Competing interests:
Have been involved with dealing with issues of 'abuse', including by 'professionals'.
Competing interests: No competing interests