PoPulationand Public HealtH etHics

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practice Cervical cancer is relatively uncommon, and the mortality rates associated with it are low. In Quebec, the participation rate for cervical cancer screening was estimated at 74% in 2008, up 3% from 2003. The data supporting the strategy to promote screening through personal invitations show modest gains, but the interventions arising from screening can involve some risks, especially for women of childbearing age. The expected population impact on women’s health — the amount of good done — would thus be fairly small. From this perspective, the method used to identify the women to be targeted by the letter proportionally loses a part of its justification. The creation of the proposed database to identify women with non-compliant behaviour, in the absence of any mechanism to let them consent to this process, seems out of proportion to the population benefits of the proposed intervention in terms of preventing cervical cancer. As the ethics committee understood it, the main justification for taking action regarding this cancer was not its prevalence, but that it is considered an avoidable problem. The idea that cervical cancer could be eliminated exerts a powerful attraction both scientifically and symbolically. The ethics committee found that sending a personalized invitation on the proposed basis did not seem legitimate in the specific context of this project. The committee therefore recommended the exploration of approaches to promoting cervical cancer screening that were more respectful of women’s privacy. Scenario shift The ethical issues would be different if the reminder to take a Pap test did not involve the cross-referencing of data proposed here to create the database for the target population. This would be the case, for example, if there were a systematic screening program that included a central registry of data on the women concerned. One can imagine that at its launch, such a system would already include all of the data on the women to be targeted. Questions for discussion 1 Are there any other things that should have been considered in this case but were not and that could have altered the committee’s assessment of the project’s justifiability? PoPulation anD Public HealtH etHics 146
2 Why did the ethics committee find that a personalized letter of this kind would have been acceptable if it had been sent in the context of ongoing clinical relationships with the women concerned rather than by the government? 3 If the committee had deemed the project legitimate, what restrictions would have had to be established to protect privacy in light of the advanced abilities of today’s information systems to store and crossreference personal data? For example, should systems be developed to do systematic tracking for a whole range of specified pathologies? 4 In attempting to address the low participation rate of some women in cervical cancer screening, this project would have led to overscreening of other women, meaning an excessively high frequency of Pap tests. The treatment (or as some would have it, overtreatment) of lesions that would otherwise disappear spontaneously in these women might lead to significant morbidity. 4 What light does this shed on the ethical issues involved in cervical cancer screening? 5 There are some major differences between cervical cancer screening practices in North America and in Europe. For example, the screening age appears to range from 18 to 21 in North America and 21 to 30 in Europe. The younger the persons screened, the greater the possibility of detecting benign lesions associated with human papilloma virus and hence of treatments that might have undesirable consequences, whereas in general these lesions would regress on their own. How should screening guidelines be designed to take this ethical consideration into account? reFerences 1 Comité d’éthique de santé publique. (2011). Avis portant sur le projet pilote d’invitation personnalisée pour le dépistage du cancer du col utérin. Quebec City, QC. 2 Ministère de la Santé et des Services sociaux du Québec. (2008). Programme national de santé publique 2003–2012. Mise à jour 2008. Quebec City, QC. 3 Goggin, P. and Mayrand, M. (2009). Avis sur l’optimisation du dépistage du cancer du col utérin au Québec. Institut national de santé publique du Québec. 4 Groupe de travail sur les lignes directrices pour le dépistage du cancer du col utérin au Québec. (2011). Lignes directrices sur le dépistage du cancer du col utérin au Québec. Institut national de santé publique du Québec. Using personalized letters of invitation to increase participation in cervical cancer screening 147
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PoPulationand Public HealtH etHics
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contents Acknowledgements - page 5
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acknowleDgeMents The Partners would
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» Create a tool to support instruc
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Each of the discussants took on thi
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Twenty years on, things have change
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intervention (say reduction in mort
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ethics understands dilemmas not onl
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priority setting. 17 Once more, usi
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6 See for example the WHO Commissio
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obesity surveillance in scHool cHil
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esearch 2 Inevitably children will
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esearch Case discussion in response
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It would be ideal to get active inf
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esearch participation, leading to a
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to sHare or not to sHare? Secondary
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esearch Scenario shift » What if t
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esearch Many different parties have
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esearch of his concern for people w
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esearcH etHics anD conFlicts oF int
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esearch and non-public information
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esearch reFerences 1 Public Health
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esearch Key ethical dimensions Perh
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esearch such support, seen across t
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esearch Proposed resolution Enablin
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a tool For etHical analysis oF Publ
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esearch are explicit. In Quebec, su
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esearch reFerences 1 Bayer, R. and
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Part two Policy
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policy being increasingly introduce
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policy behaviour. Therefore, the et
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policy 18 Chapman, S. and Freeman,
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policy through outdoor smoking, any
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policy that this is an injustice. W
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DeFerring blooD Donation FroM Men w
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policy 26 per cent of new infection
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policy 6 NHS Blood and Transplant.
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policy public trust might also incl
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policy lived in certain regions in
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policy 4 Zou, S., Musavi, F., Notar
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policy Case description For nearly
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policy 3 Economic conditions could
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policy essential to examine the his
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policy lMICs. Evidence-based introd
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policy governments, regional develo
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First nations Drinking water Polici
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policy federal government was aware
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Page 142 and 143: practice Getting Clear on What’s
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Page 182 and 183: practice The ethical principle of b
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