DuMontier Clark, Dale William, Revette Anna C, Roberts Jane, Sanyal Ameya, Perumal Neha, Blackstone Eric C, Uno Hajime, Whitehead Mary I, Mustian Lewis, Hshieh Tammy T, Driver Jane A, Abel Gregory A
Veterans Affairs Boston Healthcare System, New England GRECC, Boston, USA.
Brigham and Women's Hospital, Boston, MA, USA.
BMC Med Ethics. 2025 Jul 24;26(1):105. doi: 10.1186/s12910-025-01255-9.
Over-/undertreatment are pervasive in older adults with cancer, and challenges arise in applying the principles of bioethics: beneficence, nonmaleficence, justice, and patient autonomy. The objective of this study was to determine whether these ethical principles relate to over-/undertreatment for older adults, and how tensions among the principles may contribute.
We conducted a modified Delphi study with 13 experts in biomedical ethics for iterative rounds of data collection. In the first round, we presented via electronic questionnaire our previously published definitions of over-/undertreatment in older adults with cancer. We then asked which ethical principles related to each definition, followed by how over-/undertreatment might arise from conflicts among different ethical principles. Consensus for each question was defined as ≥ 75% of experts answering "agree" or "strongly agree". The second round consisted of a virtual discussion with nine of the panel experts led by a qualitative researcher to summarize round one results and review questions that did not reach consensus, followed by a second questionnaire including those questions.
Experts reached consensus that beneficence, non-maleficence, and autonomy were related to over-/undertreatment in older adults with cancer. Consensus was reached (92%) that overtreatment can occur when oncologists overemphasize beneficence valuing the potential benefit of cancer treatments, while underemphasizing non-maleficence with respect to treatment toxicities. Consensus was also reached (85%) that undertreatment reflects a lack of justice in equitable consideration of cancer treatments that could provide similar net benefits in older adults compared to younger adults. Lastly, consensus was reach that, in most cases, it is unethical to make a treatment recommendation without (1) formal assessment of patient frailty (e.g., via a geriatric assessment) or (2) the opportunity for the patient to share their values, goals, and preferences.
Our findings elucidate the ethical principles underpinning over- and undertreatment in older adults with cancer.
癌症老年患者中过度治疗/治疗不足的情况普遍存在，在应用生物伦理学原则（即有益原则、不伤害原则、公正原则和患者自主权）时也面临挑战。本研究的目的是确定这些伦理原则是否与老年患者的过度治疗/治疗不足相关，以及原则之间的冲突如何导致这种情况。
我们对13名生物医学伦理学专家进行了一项改良的德尔菲研究，进行了多轮数据收集。在第一轮中，我们通过电子问卷呈现了我们之前发表的癌症老年患者过度治疗/治疗不足的定义。然后，我们询问哪些伦理原则与每个定义相关，接着询问不同伦理原则之间的冲突如何可能导致过度治疗/治疗不足。每个问题的共识定义为≥75%的专家回答“同意”或“强烈同意”。第二轮包括由一名定性研究人员主持的与九名专家小组的虚拟讨论，以总结第一轮结果并审查未达成共识的问题，随后是包含这些问题的第二份问卷。
专家们达成共识，有益原则、不伤害原则和自主权与癌症老年患者的过度治疗/治疗不足相关。92%的专家达成共识，当肿瘤学家过度强调有益原则，重视癌症治疗的潜在益处，而在治疗毒性方面未充分强调不伤害原则时，可能会发生过度治疗。85%的专家也达成共识，治疗不足反映了在公平考虑癌症治疗方面缺乏公正，与年轻成年人相比，老年患者接受能提供类似净效益的癌症治疗的机会不足。最后，达成的共识是，在大多数情况下，在没有（1）对患者虚弱程度进行正式评估（例如通过老年评估）或（2）患者没有机会分享其价值观、目标和偏好的情况下做出治疗推荐是不道德的。
我们的研究结果阐明了癌症老年患者过度治疗和治疗不足背后的伦理原则。
