Abstract Summary
Justin Biddle (Georgia Institute of Technology) - Cancer screening—or testing for cancer in the absence of symptoms—is the subject of much debate. Screening has the potential to save lives by identifying and treating cancers in early stages. However, not all cancers cause symptoms, and the diagnosis of these cancers can lead to unnecessary treatments and subsequent side-effects and complications. The debate over cancer screening is a part of a larger discussion about overdiagnosis of disease, and at the very least, the debate has highlighted the difficulties involved in balancing the risks of failing to treat against the risks of overdiagnosis (e.g., Welch et al. 2011). This paper will focus on the debate over prostate cancer screening. In 2016, the United States Preventative Services Task Force (USPSTF) published draft recommendations that men ages 55 to 69 “make an individualized decision about prostate cancer screening with their clinician” (USPSTF 2016). This recommendation is updated from 2012 guidelines recommending that no man of any age undergo screening. This shift in recommendations, which opens the door to more men getting screened, is based on a shift in values. The 2012 guidelines are paternalistic and based on the norm of beneficence; the USPSTF determined on the basis of a risk-benefit calculation that it was not in the best interests of men to undergo screening, and as such, it recommended against screening. The 2016 recommendations, by contrast, are based on the norm of respect for patient autonomy; they attempt to ensure that “each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision” (USPSTF 2016). Respect for patient autonomy requires, at a minimum, that doctors communicate clearly to patients the risks and benefits of treatment options. Drawing upon recent work on inductive and epistemic risk, I examine the processes of risk assessment in prostate cancer screening, and I argue that prostate cancer diagnosis is pervaded by epistemic risks that presuppose value judgments (Biddle and Kukla 2017). These risks include inductive risks and data formation risks—in particular, risks involved in the assignment of Gleason scores to biopsied cells. The pervasiveness of these epistemic risks creates significant and under-explored difficulties for physician-patient communication and, more generally, the achievement of autonomous patient decision making. I will examine the obstacles that must be overcome if genuine respect for patient autonomy is to be reached and argue that the obstacles are sufficiently high as to call into question the feasibility of the updated guidelines.
