Jackie's post (under 'Thinking Critically about Medical Screening') raises a really important question.....
Should people always need to give their consent prior to medical screening?
That is a really good question. I think the answer if that of course, yes, we must inform patients fully of their options and of potential risks involved, but what is interesting is how often that is NOT done. I think on one extreme almost everyone's consent is obtained before HIV testing, in most societies (I found this even in remote Africa), possibly because of the potential stigma involved. On the other hand, I don't remember ever getting anyone's consent before blood group testing, possibly because I never thought of it as a screening manouver until Jackie's post.
In fact, we are screening for potential fetal alloimmunization when checking a pregnant women's blood group. I think it would be difficult to understand why a mother would refuse Rhogam (anti-Rh antibodies) to prevent future harm to her next born child, but I suppose one could cite the very rare risks involved, as well as the fact that we rarely test the father (if both the parents are Rh-, then the couple have nothing to worry about, obviating the need for Rhogam).
Regardless, does the low risk and huge benefit of a procedure making obtaining consent less necessary? (deaths attributed to RhD alloimmunisation fell from 46/100,000 births before 1969, to 1.6/100,000 in 1990). Does the fact that the potential positive impact fall on unborn children, whose consent we cannot obtain, make a difference?
Technically, I think we should be fully discussing these issues with pregnant women, but there are also 12 or so other screening tests recommended during pregnancy and we typically only get 20 minutes or so! Yikes!
Any advice?
Sources: http://www.sogc.org/guidelines/public/133e-cpg-september2003.pdf
http://www.patient.co.uk/doctor/Haemolytic-Disease-of-the-Newborn.htm
Fascinating that fathers are rarely tested, even though this might obviate the need for Rhogam.
oh and this might be relevant!
http://www.annfammed.org/content/10/6/495
I think screening for an actual disease or condition diagnosis, such as sickle cell and HIV, is taken more lightly than screening those at risk. People with the disease may be greatful you diagnosed it and now have the option to treat it.
Whilst screening those who are at risk, are left with needing to make a desision to be screened, along with the feeling of uncertainty and the psychological feelings of what will happen if they are or are not screened. I think it is in this case, there is a chance that the harm of screening is greater than the risk. Therefore, i think in this case it is most important to get consent.
Of course as a medic it is always important to get consent, but blood used to be HIV tested without consent and so medical staff didn't have to inform you if you tested positive. Although I am not sure whether this is the case now?
It really helpful to make this distinction explicit Shivani - between screening for disease and for risk.
I'm unsure whether one is taken "more lightly" than the other.... perhaps just differently? ....a positive result in one potentially leading to diagnosis and treatment, the other being less clear cut?
Sarah, the distinction is what for me gets a little bit greyish. Like in the case of HIV - Provider initiated routine testing with and an 'opt-out' approach is practiced due to high HIV prevalance in my country (Botswana). However as is the case with many routine screenings it is not implemented optimally. But basically how it works is any patient presenting at a public facility must be given information on HIV and then offerred the test (If they do not have a known status already) regardless of what they are presenting with. Of which if they consent they will undergo pre-test counseling before being tested onsite (mostly) using a rapid test. They will then be post-test counseled to recieve the result and then supported with counselling or treatment if they need it.
For pregnant women there is even a greater number that get tested (~98%) through the PMTCT program which seeks to identify all mothers at risk of transmitting the virus perinatally. Once they are found they are offerred prophylaxis or ART therapy depending on thier CD4 levels.
So my dillema is in trying to understand whether both these cases present screening for risk of for disease.
