J Epidemiol Community Health doi:10.1136/jech-2012-201194
To nudge or not to nudge: cancer screening programmes and the limits of libertarian paternalism. Thomas Ploug, Søren Holm, John Brodersen4
In this article Ploug and colleagues discuss the influence exerted upon a woman’s choice of participation in the Danish breast screening programme in light of ‘libertarian paternalism’. The basic tenet of ‘libertarian paternalism’ is outlined and the relationship between libertarian paternalism’ and informed consent investigated.
It is shown that for several reasons the influence exerted upon women’s choices of participation cannot be justified within a welfare-enhancing libertarian paternalistic framework. ‘First, the invitation to participate in the screening programme and the accompanying information leaflet should adequately present readily understandable information about the potential harms of participating in the screening programme…Second, the default enrolment rule should be changed from opt-out to either mandated choice or opt-in…Third, DNBH should abstain from making any recommendations ‘based on the weighing-off of the pros and cons’. The DNBH should not add its authority to one particular course of action.’
The same could be said of the NHS breast screening programme. ‘Choice can be influenced through wording or presentation of options’ (the NHS information provided has not been honest) and ‘through institutional default rules’ (the letter of invitation contains a pre-booked appointment).
Now that the significant harms and lack of effectiveness of screening have been identified and confirmed, (‘of 2000 women being screened for 10 years, 10 will unnecessarily be diagnosed with breast cancer and have parts or the whole …breast removed and some of these will receive radiation therapy and chemotherapy’) 1 surely healthy women should no longer receive a set appointment (and follow up letters if they decline) ? ‘The validity of consent can thus be undermined…’
1 Brodersen J. Jorgensen KJ, Gtozsche PC. The benefirs and harms of screening for cancer with a focus on breast screening. Pol arch Med Wewm 2010;120:89-94.