The ethics of medical diagnosis. Between laziness and incarceration.
Gonzalo Herranz, department of Bioethics, University of Navarra, Spain
lecture in General Session
Galician Institute of Medical Education
Santiago de Compostela, March 6, 1990
Classical diagnostic deontology
The ethical obligation to be critical
Preliminaries
Words for the occasion.
Gratitude and joy to return once again to Compostela.
Congratulations on creating an IGEM.
When I received the invitation from my colleague and friend, Dr. Juan Antonio Braña, to come here today, I suggested the topic for my lecture , which appears in the program. The Ethics of medical diagnosis is a subject that is beginning to concern and interest me. It seemed to me, moreover, that it was the most in keeping with the topic -Clinical Semiology- which is the content of the General Courses offered by the Institute this year.
The first thing we should do is to ask ourselves whether ethical conflicts arise and what they consist of when the physician makes the diagnosis of his patients, and, if they do, at what levels they occur, and what their species are.
If, to begin with, we start from a simple definition of ethical conflict -that which, without being of a technical nature, makes the physician doubt what to do, i.e., forces him to consider which decision, among several, to take in order to procure the good of his patient- we understand that ethical conflicts are of ordinary administration in the physician's diagnostic work , they are a regular ingredient of his task. They may not be as frequent as the technical problems of diagnosis, such as those posed by the interpretation of an uncharacteristic endoscopic image, an erratic biochemical parameter, a dubious biopsy finding or a surprisingly negative examination. But one thing is clear: among physicians, particularly those who are most sensitive to the quality requirements of professional care, ethical problems often arise at very different levels of their diagnostic activity.
And so, the physician may ask himself: are obtaining a blood count and white blood cell count formula or determining the erythrocyte sedimentation rate part of the routine examination that is due to all patients, so that excluding them is almost tantamount to negligence? Does the policy of cost containment justify depriving a patient of an examination that, although costly, can sometimes contribute to a better design of treatment? Can a physician accept from an insurance institution an economic incentive conditioned to the reduction of costs below the average established for the diagnosis of each disease? Is it ethically correct - and under what conditions - to perform a diagnostic test without knowledge - and, therefore, without the patient's consent? To what extent is the physician obliged to objectify, by means of a bacteriological analysis, the diagnosis of a disease that seems clear to him, both from the clinical symptomatology and from the epidemiological circumstances? Is the excess of diagnostic tests, some of them bothersome or risky, to which patients in a professor hospital are subjected, always justified?
As we can see, there is no lack of subject for reflection. I have tried to follow closely what is written on the Ethics of diagnosis. I also like to have conversations, more or less enlightening, with colleagues in my School about cases and problems that they experience intensely.
I will not attempt to make a classification and a general doctrine of the ethical conflicts of medical diagnosis: I still know too little about the topic. I can, however, in order to provoke interest and concern, comment on some of the material I have gathered, describe some aspects of the problem and highlight some of its dimensions. For guidance, these are the points I want to touch on: First, I want to describe the classical Deontology of diagnosis. Then I will analyze two manifestations of laziness: lack of criticism and hypocompetence. Finally, I will consider the phenomenon of diagnostic ingratiation.
Classical diagnostic deontology
There is not even an article in our Code of Ethics specifically dedicated to describing the ethical requirements of medical diagnosis. The Code seems to imply that the diagnostic moment of the doctor-patient relationship is one more typical element of this relationship, which shares the ethical features common to the whole of it. Indeed, article 22 of the project of the new Code states in paragraph 1: "All patients have the right to medical care of a scientific and humane quality. The physician has the responsibility to provide it, whatever the modality of his professional internship , committing himself to use the resources of medical science in a manner appropriate to his patient, according to the medical art of the moment and the possibilities within his reach".
There is, therefore, an obligation to establish the diagnosis on a solid scientific basis, since there is a commitment not to deprive any patient of those resources of medical science that are, together with due diligence, an essential part of the medical art of the moment, of the ad hoc Lex Artis of the jurists. There is also an obligation of humanity, to provide each patient with quality care staff, attentive and compassionate-, adapting resources to the needs of each patient.
In the deontological tradition, and also in the legal tradition, diligence, the sufficiency of the means applied to reach the diagnosis, was required as the primary obligation of the physician; not, however, the correctness or objective accuracy of the judgment. A diagnostic error, in itself, cannot constitute a deontological fault: the empirical fact that there are differences of opinion among competent physicians about the diagnosis of certain patients, and the complex and at the same time provisional nature of Medicine itself, have created the tradition that the physician cannot be obliged to be correct, to be infallible. The inability to make a diagnosis at the first meeting with the patient, the need to change a first diagnostic impression that turned out to be erroneous, the hesitation in the face of a difficult differential diagnosis are not morally reprehensible, if the examination has been conscientious and diligent. Neither is the therapy that, in situations of diagnostic uncertainty, the physician has to establish in order not to neglect the case and even as an indirect diagnostic procedure : it is the classic diagnosis ex juvántibus. What the deontological and legal tradition imposes on the physician is the duty not to act lightly, not to neglect the means that the science of the moment advises to clarify the diagnosis of his patient, those that a competent physician and manager would apply in the same circumstances. article 36 of the Code of Deontology of the Order of Physicians of France specifies it precisely: "The physician is obliged to make his diagnosis with the greatest care, devoting the necessary time to it, using as far as possible the most appropriate scientific methods and, if necessary, surrounding himself with the financial aid of the most competent colleagues".
But, although it does not oblige the physician to be correct, classical Deontology sets the measure of diligence required of him very high: he exercises his profession, according to the Hippocratic Oath, as best he can and knows how, that is to say, with skill and good judgment. The London Code states that the physician "owes his patient complete loyalty and all the resources of his science". And it adds that "whenever a physician sees that any examination or treatment is beyond his ability, he shall call for financial aid from another physician who has the necessary skill ".
The physician who lives in the Hippocratic tradition is diligent in attentively and intentionally obtaining the clinical history: he listens with tense interest to the patient's story, because he knows that certain substantial, clarifying data about the disease can only be revealed to him by the patient. He does not allow any prejudice or feeling that the patient may inspire in him to interfere with the quality of the care he must administer to him: he does not label his patients with moral, political or characterological stigmas: he must treat them all as human beings equally worthy of respect who present him with problems of identical scientific interest. He is not ethically authorized to distinguish, and to treat his patients differently: there are not for him those who are scientifically interesting and those who are routinely common, those who are lovable and those who are hateful, those who are like-minded and those who are strangers. He knows that such interference always and inevitably damages the quality of his care.
He performs the physical examination with his five senses wide awake. He investigates with order and system that object of scientific inquiry that is the body of his patient. He respects the staff and bodily intimacy of the patient. He does not unnecessarily or gratuitously invade the strata of the private or hurt the modesty of the naked body. He knows that the Withdrawal to the dignity of the clothed and erect body that the patient makes when undressing and lying on the examination table, puts on his shoulders the obligation to take care of his modesty and to abstain from any erotic relationship on the occasion of the physical examination: the visual inspection is not a look with ulterior motives, nor the palpation a caress. Abusing this status would not only be a frivolous indecency. It is above all an injustice and an aggression. Classical Deontology demands, with sapient experience, that in the exploratory act a nurse should always be present. The American Psychiatric association has just imposed it on its members.
Where his senses cannot reach, the physician reaches with his instruments of exploration, with his laboratory methods. I have never understood why some people think that the introduction of diagnostic technology must necessarily be linked to a loss of humanity. Technological instrumentation has, in medicine, a profoundly human, delicate sense, which not only provides data of extraordinary precision and diagnostic significance, but also saves time, pain and uncertainty.
Once the data have been collected, the physician has to sort them out, refine them, integrate them, so that he/she can draw up a plausible diagnostic hypothesis. There are many ways of elaborating this intellectual phase of diagnosis, many different styles of doing it. I came to see how some masters of classical clinical and pathological Anatomy worked (Eduardo Ortiz de Landázuri, Agustín Pedro Pons, Adolfo Ley, Erich Letterer). What was most characteristic of them was their two-phase approach: first reflexively and then confidently. They knew that their brain was their most powerful diagnostic instrument. They were persuaded that a balanced mixture of prudence and intellectual daring was necessary to arrive at the diagnosis. They felt that the diagnostic operation was, as a whole, something full of incentives and risks, a wager in favor of intelligence, of the adventure of taking risks and an occasion to practice, when necessary, the humble and inevitable function of rectifying.
The moral obligation to consult the most competent colleagues is also, as we have already seen, a legacy of the deontological tradition in which we still live, having forgotten the elaborate ceremonial of the classical enquiry . The Deontology of the time was well aware that this necessary cooperation was liable to degenerate into roguish business deals, unnecessary consultations with the specialist, superfluous requests to the laboratory or the radiology office, clandestine fee splitting, and dichotomy agreements. Dignified physicians have been able to see in this degeneration of interconsultation that what is harmful is not in the economic injustice that is inherent to it: what is truly antideontological is in choosing the diagnostic partner not for his skill, but for his venality.
An important facet of the classic deontology of diagnosis refers to the way in which it is to be statement to the patient and his or her relatives. Of course, the communication of the vast majority of diagnoses does not pose any particular problems either to the physician or to the patient: it is news that comes to alleviate the anguish or the diffuse fear that every illness creates in the sufferer, who is sometimes prey to very pessimistic presentiments. On other occasions, however, the diagnosis is news that shatters long-cherished projects, that means much suffering and limitation, or that sometimes confronts the patient with an unfortunate, short-term prognosis.
article 12, 4 of the project of the new Code of Medical Ethics reads as follows: "In principle, the physician shall inform the patient of the diagnosis of his illness and shall inform him with delicacy, circumspection and a sense of responsibility of the most probable prognosis. He shall also do so to the patient's next of kin or other person designated by the patient". The physician will then act with prudence. He will keep the natural discretion and will not divulge news that may be coveted by some, but which belongs exclusively to his patient and to those persons he designates. To them, the physician will tell the truth, according to his capacity to assume it, dosing it wisely, without exaggerating it and without turning it into a traumatizing agent. He will know how to tell it with such an accent that he manages to mobilize in the patient his responsibility and the acceptance of his destiny. He will not crush their hope nor will he open them to illusory expectations, but he will have to make it clear to them that they will never lack neither financial aid nor the company of their doctor.
These and many other ethical aspects of the classical deontological doctrine. Its richness will make it permanently valid. And yet, we have the impression that, in medicine, things have changed so much that many of the rules and customs of the past are no longer applicable today. The place and environment of diagnostic enquiry , the pace of work, the interprofessional partnership , the taxonomy of diseases, the aspirations of patients have changed. Above all, the way physicians think and diagnose has changed. Everything seems to indicate that classical deontology is too narrow for today's diagnostic activity and that it is insufficient to embrace its complexities. Many of these complexities, although ethical in their essence, are very often manifested under the guise of economic, technological, organizational and, as is always the case in medicine, profoundly human problems.
I think, however, that in the classical Deontology we have the ethical principles necessary to face with optimism the present and future problems of medical diagnosis, as long as the physician knows how to overcome laziness.
The ethical obligation to be critical
Today's diagnostic work requires the physician to put all his intelligence into it. This means that a physician who is not capable of offering a sincere and convincing explanation, calmly critical, of why he/she has chosen certain resources to arrive at the diagnosis, would not be practicing ethically the diagnosis. The physician is obliged to obtain laboratory analyses and tests, X-rays, clinical-physiological tracings insofar as they are relevant, that is, insofar as they contribute to establishing and affirming the diagnosis. Therefore, the physician should always be able to satisfactorily answer questions such as: why he/she performs or omits certain examinations, why he/she considers that some of them are superior to others in their diagnostic efficacy, how he/she decides for each of his/her patients which are the minimum tests necessary to establish the diagnosis.
Most physicians are still reluctant to reveal the mental process they follow to arrive at a diagnosis. They think it is a very difficult skill to describe, being partly intuitive and artistic, partly more rational and explainable. But it turns out that, in recent years, the mental structure of the diagnostic process has been the subject of vigorous analysis by some clinicians who are experts in the language of logic and statistics, who, together with computer scientists, psychologists, logicians and engineers, have begun to dismantle and classify its various parts and mechanisms. What happens in the minds of doctors when they diagnose moves in a field of tensions, with a scientific-statistical pole and an artistic-intuitionist pole. What is now being analyzed is the extent to which the conjectural element is, at bottom, something that can be explained by such respectable sciences as probabilistic logic or decision theory. And it is also about understanding that not everything that is part of clinical reasoning can be reduced to algorithms or associations that respond to mathematical models. As expert systems are developed for the financial aid of clinical diagnosis or for the interpretation of the findings of complementary examinations or for the deduction of the most probable diagnosis, we will gain a deeper understanding of the mental mechanisms of the physician that artificial intelligence expert systems try to imitate.
However, we are not interested here in the intellectual aspects, but in the ethical aspects of today's diagnosis. Some argue that the hectic, unsettled pace that is imposed today on the physician's work in outpatient clinics or hospitals is a very serious obstacle to the physician's ability to apply all his intelligence and conscience to diagnostic work . Often, the physician is forced to dispose of his disproportionate workload in any way he can. He then runs the risk of exhibiting paradoxical behavior: instead of offering his patients a solidly substantiated diagnosis, he administers to them, as a placebo to relieve their anxiety or as entertainment to distract their arrogant demand for attention, a list of complementary examinations and laboratory tests.
The exciting task of fill in and weighing the data of the problem and making a differential diagnosis, the highest intellectual activity of medical internship , is no longer performed as often as it used to be. There has been, in the daily task of many physicians today, a dilution of intelligence, which they try to compensate for by an abuse of technology.
Let's take an example to illustrate what I'm saying that describes, in its own way, a common phenomenon: how overreliance on technology causes a retraction of intelligence. In a recent article in Chest, they talk about how much fiberoptic bronchoscopy is abused. "To establish the need for bronchoscopy, it is essential to take into account the epidemiological circumstances, history and physical examination. Where the abusive resource of CT or MRI is causing an atrophy of diagnostic skill based on history and physical examination, the issue of poorly indicated bronchoscopies is increasing. Many patients whose pneumonia takes a long time to resolve or who have a lung abscess undergo bronchoscopy because their physicians are not reassured until the possibility of obstructive bronchial cancer is excluded. This happens because physicians have lost confidence in the history and physical examination. That same loss of confidence contributes to the ambiguity of the radiological reports. The physician gives the radiologist little clinical information. The radiologist is then unable to be specific and, to cover his back, includes obstructive pneumonia or cavitary cancer in his range of suspicions. This radiologist's report ends up paving the way for unnecessary bronchoscopy. At this point, no one wants to delay any hard diagnostic procedure that might uncover cancer, however leave the chance of proving it: bronchoscopy and CT end up being done. But none of these techniques is justified? Today, when a diagnosis is in doubt, physicians are more inclined to use costly and cumbersome endoscopic or imaging techniques, rather than return to the patient's bedside and hear more about the onset and course of the disease from the patient's lips".
That is a fairly realistic description of what is going on. It seems that many physicians have become agnostic about the value of anamnesis and doubt that physical examination is of much use. The withdrawal of that ancient conviction is making medicine more expensive and is replacing the use of intelligence with the ritual of filling out forms requesting laboratory tests and state-of-the-art examinations. It is necessary to recover the frugal and intelligent use of diagnostic resources, which is both more fun and more compatible with a high quality of care. Moreover, the withdrawal of intelligence does not only cause a loss B economic resources: it also leads to a loss of diagnoses, atrophies professional skill , and is of inferior ethical quality.
When physicians are asked to give an explanation for the excess of analyses and complementary tests they request, they respond that such behavior is motivated by several factors: one is the desire not to omit obtaining any potentially significant data and to show that nothing has escaped the suspicions of their alert mind; another is to prevent the risk that, by lacking some data, the patient's diagnosis will be delayed and the patient's stay in the hospital lengthened; a third is not to incur the displeasure of the boss for not having foreseen that such and such a test was going to be necessary.
These circumstances tend to create an obfuscated mentality. One ends up thinking that, if it is good for the diagnosis to be based and consolidated on laboratory data or complementary tests, the more data obtained, the better the diagnosis will be. This mentality is blind to an important part of reality: the high cost of these tests and their low yield.
There are many works in the bibliography devoted to showing how extensive and intense is the ignorance of physicians about the cost of diagnostic tests. But the seriousness of the matter is that the behavior of many physicians does not change, or changes only temporarily, when they are informed of these costs and that the idea that high cost and quality are inseparable is a fallacy. What Donabedian has called the "principle of parsimony", i.e., that excessive diagnostic prescribing, even if harmless, is a manifestation of carelessness, lack of judgment or ignorance, which squanders available resources, which are always insufficient. Moreover, superfluous tests and examinations are not always harmless, as they sometimes entail unnecessary risks, cause significant side effects and reduce the overall quality of medical care.
Pellegrino includes, in a fundamental article on The Anatomy of Clinical Judgments, some rules for achieving clinical prudence. I translate them below, emphasizing their ethical implications. They read as follows:
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Act in such a way that, as far as possible, you increase the benefits and decrease the risks.
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Try never to overlook what is serious and treatable; you can, on the other hand, ignore what is not serious and for which there is no treatment.
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Apply Ockam's rule to clinical matters: Do not multiply complementary examinations, analyses or diagnoses without justifiable need.
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Do not easily elevate any diagnosis to definitive.
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Clinical skepticism is the only safeguard against the tyranny of a "consolidated" diagnosis, ancillary data or the opinions of colleagues.
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He often suspects that common diseases may have uncommon manifestations.
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"Hoofprints don't mean zebras," unless there are zebras in the vicinity.
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When the data is falling into place, the only safety in the face of error is to remain nonconformist.
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Know yourself: your clinical style, your biases, your convictions about what you believe is good for patients.
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Do not trust your hunches, your intuitions. You can risk your own prestige in a bet, but not the fate of your patient.
Commenting on these rules would take us too far. But it is worthwhile, while we still have them in our report, that we consider the need to keep up to date in our report a judgment on the diagnostic value of each test and each examination. (The factor that most strongly opposes scientific progress is the viscosity of ideas, the tenacity with which they adhere to our report and how difficult it is to practice the art of forgetting). We need to evaluate in order to evolve, to overcome the mental laziness of a report that does not change its contents.
Diagnostic tests should, like pharmacological remedies, be subjected to a clinical essay to quantify their efficacy and risks, their reliability and their limitations. The bibliography needs to be much more populated by conclusions that state: "Maternal age of 36 years or more is another risk factor to continued normal gestation after chorionic villus sampling, as it causes a significant increase in the rate of miscarriage, especially when it has been necessary to introduce the catheter more than once".
In the last ten years, the assessment of diagnostic technologies and the precise quantification of their benefits, but also of their risks and costs, have been implemented. Curiously, the published studies (including the series sponsored by JAMA) seem to have had very little influence on the behavior of physicians. There are many factors that lead to this attitude: that physicians pay more attention to programs of study that favor the consumption of technology - promoted by manufacturers or by optimistic physicians who are no strangers to conflicts of economic interests - than to those carried out by agencies that pay for medical care - logically interested in reducing this consumption; that the speed with which technologies evolve tends to make even recent assessment obsolete; that it is very difficult to obtain an untainted objectification of clinical efficacy, etc. But there is no doubt that technology assessment is called upon to be a basic ingredient in the ethical development of medical diagnostics: it can provide a description of the level of quality and applications of each technique; it can help to distinguish between unconfirmed diagnostic possibilities and the substantive data that support a specific application; above all, it can help, if such an assessment is made in the initial phase of application of the new technology, to design prospective programs of study to determine its selective uses, its limitations and its risks.
Things, however, do not move only at the high-tech level. The physician has to apply the assessment of analytical data to his most ordinary internship . Millions of laboratory tests are requested every day, many of them superfluous: either because they do not even reach the knowledge of the physician who requested them, or because the physician disregards them because, when he receives the results, they are no longer relevant. It would be an interesting exercise to ask physicians if they know the analytical imprecision of the laboratory they use for each of the determinations they request; if they know how much the intra-individual variation can be for biochemical and hematological parameters; if they take into account the pre-analytical sources of variability; if they have tables of the critical differences between results necessary to diagnose that there has been a significant improvement or worsening in the evolution of such data. Is it known to the average physician that a difference in serum cholesterol concentration requires a variation of 19% to be considered significant; that leukocytes must differ by 32%, platelets by 25%, or hemoglobin by 8%, for significance to be attached to any observed rise or fall? If after three months of dietary treatment, the cholesterol concentration is observed to have dropped from 7.62 mmol/l to 6.49 mmol/l, does that mean that the per diem expenses have been effective, or is it simply a change that may be due to intra-individual or analytical biological variation?
Such questions must be answered subject The physician must know which variations in the analytical parameters are significant and justify a clinical decision. This implies that they must try to distinguish the chaff of the changes due to analytical or individual variability from the wheat of the truly critical differences.
When talking about this topic with some resident physicians, one of them told me that to put things this way was to freeze Medicine, to put it on the level of something coldly mathematical. I reminded him that this was not the case at all. The doctor's concern for the human always begins with the scientific correctness of his decisions and actions: that is the first duty of humanity. And I encouraged him, in his work, not to forget that medicine can never be too scientific or too humane. To be one of both it needs to be the other to the highest Degree. The threat always comes from that form of laziness which is hypocompetence, from not striving to live up to the human and scientific standards of Medicine.
Some programs of study have recently been carried out on the correlation between the physician's psychological typology and his diagnostic behavior. There are many physicians who think that overdoing it is better than underdoing it, because it is assumed that the physician is always obliged to make a diagnosis, he must necessarily do so. These doctors think that it is much worse to tell a sick person that he is healthy than to tell a healthy person that he is sick. And, curiously, it seems that the judges who hear internship cases agreement with them. This strategy of "better to overdo it than to underdo it", of "better to go for the safe side than to regret it later", leads to two destinations: to over-diagnose (with the possible added value of scoring a spectacular triumph), to cure a cancer that never existed, to cure a cancer that never existed, to cure a cancer that never existed, to cure a cancer that never existed, to cure a cancer that never existed: curing a cancer that never existed, coming out with a modest loss (a stomach, a breast) when it seemed that everything was going to be lost - and that thanks to the doctor's expertise - or suspecting on the worse side and performing aggressive and expensive diagnostic tests in search of a diagnosis that, although more improbable, is more serious and spectacular.
These two forms of exaggeration in diagnosis seem to be tolerated forms of interindividual variation among physicians, two different styles of action, but they should be censured from an ethical point of view. The fact that a new technology is available does not authorize its abuse. It sometimes seems that no one wants to give up the prestige of "being up to date, of being on the cutting edge". And, least of all, the patient who wants to be investigated with what is the latest novelty, the latest fashion, in diagnostic technology, which yesterday's television news talked about.
Of all the procedure recently offered by medical technology, it is common to lack convincing and proven evidence that their application has a positive effect on the patient's fate; that their sensitivity, specificity and diagnostic efficiency have been evaluated and found to be satisfactory and superior to other accepted and widely used procedures; or that their mass application is economically advantageous. Even in the case of invasive procedures, there is a lack of convincing evidence that the physical risks of the test are sufficiently justified by net benefits measured in improved patient care.
Someone has suggested, as is so often the case in Bioethics today, an image from ancient mythology to describe this uncontrolled drive to use everything new and use it abundantly: it is the image of the hydra, the many-headed monster that was the object of one of Hercules' labors: when he cut off one of its heads, two grew rapidly in its place. Hercules multiplied the work ahead of him as he became more efficient in doing it.
There are hospitals and Departments where certain technology is abused, without any objective improvement in the quality of care. Robin, the author of the parable of the hydra, has also created the syndrome of the Lemmings, the monkeys that walk in single file, following the leader, to point out how physicians tend to follow the internship that has been dictated to them by what they learned during their initial or continued training.
These habits, together with the economic incentives linked to the offer of extensive technological menus that attract customers, are the cause of more than 4.5 million superfluous tests being performed daily in the United States, 18 to 25% of the estimated $400 billion in health care costs, according to 1987 estimates, being spent out of the bucket.
In the wave of enthusiasm created by a new laboratory test , the physician can do more harm than good. This is the case with the detection of subjects who respond to the hepatitis C virus antibody test . It is known that a good proportion of anti-HCV positive individuals will suffer from chronic and potentially fatal liver disease. But many others will not. Many will infect, many will not. But we do not know how to distinguish between one and the other. Should we tell everyone that their fate is homogeneously good or bad, that they should take precautions not to infect other people with whom they live or forget about them? What influence should the result have on the possibilities of employment, of social coexistence, of obtaining life insurance? Will they be (mis)treated in the same way as HBV carriers? Of course, the test should be used on subjects in risk groups. But is it ethical to use them, just for the sake of knowledge, in normal or low-risk populations? A doctoral thesis is not worth the happiness of some people. "The interests of science or society may never prevail over those of the individual", the Helsinki declaration states twice.
In addition to this diagnostic zeal driven by the desire to know, to apply, without discretion and without prudence, there is another, more parallel to the therapeutic zeal: the one that leads to not letting anyone die without intensive diagnostic care.
Defensive medicine has created an overdose of diagnostic tests.
Thank you very much.