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TVCS meeting
on 30 March 2000 at Whittington Hospital, Highgate
Dr John Nottingham
explained how informed consent and population screening addresses
a tension between what 'sounds' impressive as a result of a medical
test and what occurs spontaneously in a range of normal people.
He endorsed
Dr Angela Raffle's claims that "Screening has distorted public
belief and which criticises the NHSCSP for its 'target mentality'.
There are problems inherent in smear test reporting which perpetuate
unrealistic expectations and screening programs fail to give sufficient
information to patients causing anxiety arising from results.
The doctor patient
relationship is reversed for screening, i.e. the doctor asks
you to have the test. A duty of care still rests with the doctor
to inform patients regarding all aspects of having the test.
The General
Medical Council guidelines on getting informed consent ask
- that doctors
explain the purpose of screening;
- the rarity
of the disease;
- the risks
attached to screening; and
- follow-up
plans including availability of counselling and support services.
- The GMC guidelines
also state that information necessary for voluntary decision
making should not be withheld even if a consequence is that a
woman refuses the test.
However, in
the targets for uptake, and targets for abnormal ranges, guidelines
exclude possibilities of FN/FP results. The cause for this may lie
with the 'prevention paradox'. In rare conditions, for one to benefit,
many must be screened. Maximum coverage is of the essence, but if
women realised the rarity of the chance of developing cervical cancer
even if they have an abnormal smear, would this be a disincentive
to adopt behaviours aimed to protect health?
An informed
decision should be autonomous, and contain concrete information,
based on a realistic appraisal of risks and benefits. Dr Mary Anderson
performed a survey of information leaflets from NHSCSP and local
LA regarding cervical screening. She concluded that these were propaganda
for the test rather than accurate information on women's need for
it. There was no explanation of what a 'false' result means. Women
do not know what they are letting themselves in for.
Screening programmes
need to be more open and honest. Balanced unbiased information,
with a signed disclaimer to prove that contact targets had been
achieved could result in no pressure put on patients who want to
decline.
Refs.
Anderson CM, Nottingham JF 'Bridging the Knowledge gap and communicating
uncertainties for informed consent in cervical cytology screening'.
Cyto-pathology, 1999, 10:221-228
Austoker J 'Gaining informed consent for screening - is difficult
- but many misconceptions need to be undone'. BMJ, 1999 Vol319:722-3
Raffle A 'Informedparticipants in screening is essential '. BMJ,
1997,314:1762-3
A booklet published by the NHSCSP in January 2000 entitled 'Consent
to Cervical Screening5 is available on request
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