Carter Stacy M, Doust Jenny, Degeling Chris, 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):722-724. doi: 10.1136/medethics-2016-103822. Epub 2016 Aug 29.
It is a privilege to have respected colleagues engage with our definition and ethical evaluation of overdiagnosis. In our response to the commentaries, we first deal with paradigmatic issues: the place of realism, the relationship between diagnostic standards and correctness and the distinction between overdiagnosis and both false-positives and medicalisation. We then discuss issues arising across the commentaries in turn. Our definition captures the range of different types of overdiagnosis, unlike a definition limited to diagnosis of harmless disease. Certain implications do flow from our definition, as noted by commentators, but we do not view them as problematic: overdiagnoses can become beneficial diagnoses as medical knowledge and practice changes over time; inadequate systems of healthcare can produce tragic overdiagnosis, and the effectiveness of treatment partly determines whether overdiagnosis occurs. Complexity and uncertainty in balancing benefits and harms is unfortunate, but not a reason to avoid making a judgement (ideally one that reflects multiple perspectives). We reaffirm that overdiagnosis, for the foreseeable future, must be estimated at a population level and defend the importance of good-quality risk communication for individuals. We acknowledge that a lot turns on the relevance of professional communities in our definition and expand our reasoning in this regard then conclude with a note on the difference between intentions and goals. We expect that it will be some time before these matters are settled and we look forward to continue debating these matters with our colleagues.
能有受尊敬的同事参与我们对过度诊断的定义及伦理评估，是一种荣幸。在回应这些评论时，我们首先处理范式问题：实在论的地位、诊断标准与正确性之间的关系以及过度诊断与假阳性和医学化之间的区别。然后我们依次讨论评论中出现的问题。我们的定义涵盖了不同类型的过度诊断，这与仅限于诊断无害疾病的定义不同。正如评论者所指出的，我们的定义确实会产生某些影响，但我们并不认为它们有问题：随着医学知识和实践随时间变化，过度诊断可能会变成有益的诊断；不完善的医疗保健系统可能会导致悲剧性的过度诊断，而且治疗的有效性部分决定了过度诊断是否会发生。在平衡利弊时存在复杂性和不确定性，这很不幸，但这并不是避免做出判断（理想情况下是反映多种观点的判断）的理由。我们重申，在可预见的未来，过度诊断必须在人群层面进行评估，并捍卫为个体提供高质量风险沟通的重要性。我们承认在我们的定义中专业群体的相关性至关重要，并在这方面扩展我们的推理，然后以关于意图和目标差异的说明作为结论。我们预计在这些问题得到解决之前还需要一段时间，我们期待继续与同事们就这些问题进行辩论。
