Brandon P. Brown
Indiana University School of Medicine
 Risk as an important component in medical
prevention, diagnosis, and therapy is an evolving
concept
 Risk itself is not new, only medicine’s increasing focus
on it is new
 For example, diabetes mellitus has been described as a
high risk state rather than a true disease state
 Quantifying risk often involves multiple evaluations:
 Genetics
 History
 Physical condition
 Lifestyle
 Risk is by definition a subjective concept, yet when
statistics are overemphasized in quantifying risk they
give the artificial sense of objectivity
 Risk Stratification can become a complex issue when it is
describe in the objective terms of biostatistics
 Framing the benefits of a screening exam in terms of
relative versus absolute risk reduction can yield very
different sounding results.
 What if a patient decides against a screening exam based
on a statistical misinterpretation of the usefulness of an
exam? How can we balance the concerns of public health
versus personal inconvenience?
 Mammography
 This screening exam in particular is an excellent
example of the dilemma facing physicians: How to
communicate the concepts of risk reduction while
simultaneously being fully forthcoming and also
advocating for preventive health
 Although not always obvious, there is a tension between
patient understanding and public health interests,
especially when a patient or patients decide that a
recommendation or preventive health measure is not in
their personal best interest
 Mammography
 Several issues are at stake:
 How much to tell the patient regarding the specifics of risk
assessment and biostatistical estimates of the benefits of
screening exams?
 How to promote the screening exam while also presenting the
patient with a choice?
 What to do if describing details of a screening exam actually
dissuades patients from the exam?
 Autonomy and Beneficence:
 How to give the patient the greatest possible control over their health care
(autonomy)
 How to ensure that what is medically best is done for the patient
(beneficence)
 Although not obvious, there is a tension between patient
understanding and public health interests
 How do we report “risk” – do patients understand what purpose
mammography serves?
 i.e. – If we ask patients how well does mammography prevent cancer…
 The answer is not at all, it only helps with preventing cancer mortality
 In other words, patients can easily misunderstand the purpose or efficacy of
the screening exam
 Scarce resources: not only monetary
 There is only limited time to be spent with any given patient, and the
physician must choose how best to spend that time.
 If we think of time as a scarce resource in the same way that financial
health care resources are scarce, this question of what to tell the patient
becomes even more important.
 The biostatistical dilemma…
 Take for example a group of women ages 50-70 with average
risk factors. Looking at the absolute risk of death from
Breast Cancer:
 8.1 in 1000 for the unscreened population
 5.1 in 1000 for the screened population
 Absolute reduction of 3 deaths per 1000
 Based on these numbers alone, mammography does not
immediately strike one as very efficacious.
 This is partly true because the unscreened risk of death from
breast cancer is not very impressive at face value.
 Unimpressive sounding numbers, combined with the fear
many women have of the mammogram and the actual
inconvenience and discomfort of the exam itself, might be
enough to cause women to refuse the exam.
 Looking at the risk for the same populations, consider
the relative risk estimates:
 Relative risk
 8.1 per 1000 reduced to 5.1 per 1000 equals 37% reduction
 Screened patients are 37% less likely to die from breast cancer
– relative to unscreened patients
 The relative risk numbers are far more convincing, but
potentially more deceptive. The same exam has a risk
reduction of both 3 and 37%, depending on how the
information is framed.
 The question remains, which number should a
physician quote to his patient?
 Which number should a physician quote to his
patient?
 What about giving both numbers? Will this confuse
patients?
 Perhaps both numbers should be quoted, but explaining
the differences in absolute and relative risk and how
these numbers are arrived at will be difficult, and all
within the normal 15 minutes (at most) spent by a
primary care physician talking with the patient.
 Is there any ethical difficulty in omitting some of the
information for the sake of time or simplicity?
 Public Health: both risk assessments (absolute and
relative) are convincing
 Even the absolute mortality reduction of 3/1000 makes a
very big impact:
 In a population of 1 million people, mammography saves
3000 lives!
 Thus, what should determine information given or
withheld from patients. Just as important, who should
determine this?
 Do patients deserve complete (even if irrelevant or
excessive) information, or should the goal be simply to
encourage screening as much as possible?
 Does public health trump private autonomy?
 Imagine that a patient is indeed presented with
complete and thorough information regarding the
efficacy of the mammogram, and the patient decides
they only need an exam once every 5 years, or even
every 10 years.
 Is this an acceptable outcome? What if the majority of
patients made such a decision?
 Perhaps we do our patients a disservice by focusing
solely on “full disclosure”
 Lest we become too fixated on the autonomy of the patient and insist
on always relaying every detail of our tests and decision-making
process, it is a useful exercise to stop and consider just how many
decisions that are made without mentioning it to the patient. To
actually relay every detail of every decision, there would have to be an
enormous increase in time spent. Who is this “full disclosure” truly
intended to benefit – the patient, or the desire to cover our tracks?
 There are many types of scarce resources in medicine, and time spent
with a patient must be carefully and thoughtfully used. To use this time
in an attempt to preemptively defend decisions would be a true waste
indeed.
 Caution is required to ensure that the mantra of “ethical concern” is
not used as a mask for what in reality might be medico-legal fears.
 One bioethics expert on risk in medicine, Dr. Peter
Schwartz has put it thus:
“Admittedly, legal concerns may lead physicians to (fully discuss all
risks) because a patient who is not tested and later develops…cancer
could sue. But practicing this sort of “defensive medicine” leads to
relatively irrational ways of apportioning healthcare resources, and
may even injure more patients than it helps. In the end, an ideal
medical system would make sure that all patients make informed
decisions in such situations, but given the real limitations of the
current system, a silent decision may be the ethical one.”
 Ultimately, it is important to be mindful that we will never
be able to counsel patient on every risk, and that despite
our best efforts, preventive medicine will always be
incomplete and thus leave room for therapeutic medicine.
If (and it is a big “if”) concerns over medico-legal issues
and the expectations of our peers can be placed secondary
to concern for the immediate patient at hand, risk and
prevention can be useful assistants in our medical efforts
and avoid a fate as reflexive check-boxes in an algorithm
that sees only one kind of patient.
 Of course, there are many other examples of screening
exams, including prostate tests, colonography, CT
colonography, and chest CT, and these deserve equal
scrutiny, likely involving similar dilemmas of public
health and patient information.
 The use of mammography merely serves as a case in
point regarding what is a broader issue.

Chamot E, Perneger TV. Misconceptions about efficacy of mammography screening: a public health dilemma. Journal
of Epidemiology and Community Health 2001;55(11):799-803.

Domenighetti G, D'Avanzo B, Egger M, Berrino F, Perneger T, Mosconi P, et al. Women's perception of the benefits of
mammography screening: population-based survey in four countries. International Journal of Epidemiology
2003;32(5):816-21.

Schwartz PH. 2007. Silence about Screening. American Journal of Bioethics 2007;7(7): 46-48.

Slaytor EK, Ward JE. How risks of breast cancer and benefits of screening are communicated to women: analysis of
58 pamphlets. BMJ 1998;317(7153):263-264.
Thomson R, Edwards A, Grey J. Risk communication in the clinical consultation. Clinical Medicine 2005;5(5):465-9.
Thornton H, Edwards A, Baum M. Women need better information about routine mammography. BMJ
2003;327(7406):101-103.



U.S. Preventive Serves Task Force. 2002. What’s new from the U.S. Preventive Services Task Force: An overview of
recommendations: Screening for prostate cancer. AHRQ Publication No. APPIP03-0003. Available online at
http://www.ahrq.gov/clinic/3rduspstf/prostatescr/prostatwh.pdf

Whitney SN and LB McCullough. Physicians’ silent decisions: Because patient autonomy does not always come first.
American Journal of Bioethics 2007;7(7): 33–38.
*I owe most of the ideas in this presentation to discussions with Dr. Peter Schwartz of the IU Center for Bioethics. His ongoing original work in this
area has resulted in increasing awareness of the many concerns regarding screening exams.