Carter Stacy M, Degeling Chris, Doust Jenny, Barratt Alexandra
Centre for Values, Ethics and the Law in Medicine, The University of Sydney, Sydney, New South Wales, Australia.
Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia.
J Med Ethics. 2016 Nov;42(11):705-714. doi: 10.1136/medethics-2015-102928. Epub 2016 Jul 8.
Overdiagnosis is an emerging problem in health policy and practice: we address its definition and ethical implications. We argue that the definition of overdiagnosis should be expressed at the level of populations. Consider a condition prevalent in a population, customarily labelled with diagnosis A. We propose that overdiagnosis is occurring in respect of that condition in that population when (1) the condition is being identified and labelled with diagnosis A in that population (consequent interventions may also be offered); (2) this identification and labelling would be accepted as correct in a relevant professional community; but (3) the resulting label and/or intervention carries an unfavourable balance between benefits and harms. We identify challenges in determining and weighting relevant harms, then propose three central ethical considerations in overdiagnosis: the extent of harm done, whether harm is avoidable and whether the primary goal of the actor/s concerned is to benefit themselves or the patient, citizen or society. This distinguishes predatory (avoidable, self-benefiting), misdirected (avoidable, other-benefiting) and tragic (unavoidable, other-benefiting) overdiagnosis; the degree of harm moderates the justifiability of each type. We end with four normative challenges: (1) methods for adjudicating between professional standards and identifying relevant harms and benefits should be procedurally just; (2) individuals, organisations and states are differently responsible for addressing overdiagnosis; (3) overdiagnosis is a matter for distributive justice: the burdens of both overdiagnosis and its prevention could fall on the least-well-off; and (4) communicating about overdiagnosis risks harming those unaware that they may have been overdiagnosed. These challenges will need to be addressed as the field develops.
我们探讨其定义及伦理影响。我们认为，过度诊断的定义应在人群层面进行表述。考虑一种在人群中普遍存在的疾病，通常被标记为诊断A。我们提出，当出现以下情况时，该人群中就存在针对该疾病的过度诊断：（1）该疾病在该人群中被识别并标记为诊断A（可能还会提供相应干预措施）；（2）这种识别和标记在相关专业领域会被认为是正确的；但（3）由此产生的诊断标签和/或干预措施在利弊平衡上是不利的。我们指出了确定和权衡相关危害时面临的挑战，然后提出了过度诊断中的三个核心伦理考量因素：造成的伤害程度、伤害是否可避免以及相关行为者的主要目标是使自己受益还是使患者、公民或社会受益。这区分了掠夺性（可避免、利己）、误导性（可避免、利他）和悲剧性（不可避免、利他）过度诊断；伤害程度会缓和每种类型的合理性。我们最后提出了四个规范性挑战：（1）在专业标准之间进行裁决以及识别相关危害和益处的方法在程序上应是公正的；（2）个人、组织和国家在应对过度诊断方面负有不同责任；（3）过度诊断是一个分配正义问题：过度诊断及其预防的负担可能会落在最贫困人群身上；（4）关于过度诊断的沟通可能会伤害那些未意识到自己可能被过度诊断的人。随着该领域的发展，这些挑战需要得到解决。
