Editorial
Ann Med Downloaded from informahealthcare.com by McMaster University on 12/29/14 For personal use only.
Doing Good, Doing Harm: Adverse Effects of Screening and Health Education in Perspective Primum non nocere, says an ancient principle of medicine. In practice, respect for not doing harm cannot be absolute. Rather, we should search for an optimal balance between the benefits and harms of medical interventions. Reaching this balance is often extremely difficult in patients with severe, debilitating diseases. In contrast, screening and health education are often thought of as unproblematic in this respect. Nonetheless, they also can bring about adverse effects. People identified as positive by a screening test, or patients learning during a medical examination that they have an abnormality of some kind often become physically distressed because of the awareness of having a disease. As a consequence, they may change their behaviour dramatically. Alarm after a positive screening test is a natural reaction and may be positive if it increases the interest in taking care of one’s health. However, unnecessary problems are brought about by false positive test results. Adverse effects have been reported for screening programmes for several diseases. An early example is the restriction of schoolchildren’s activity due to innocent cardiac murmurs in the 1960s also known as ‘cardiac nondisease’. In Seattle, 93 children out of 20,500 were found to have been told that they either had acute rheumatic fever or something wrong with their heart. Of these, 18 had clinically verified heart disease while 75 had not. Among the latter, 30 children had restricted their activities because of putative heart disease. Most of the unnecessary restriction was due to the physician’s advice. The authors stressed the importance of the rehabilitation of ‘nondiseased’ children and suggested that the benefits of this might far outweigh fhe results of mass disease screening programmes (1). In the 1950%headaches were found to become more prevalent in hypertensives after they become aware of their condition (2). Several studies found that the awareness of being hypertensive was followed by increased absenteeism from work (2),emotional lability, anxiousness, depression, somatic discomfort, and insecurity, suggesting neurosis (3). A Canadian study reported increased absenteeism from work for as long as 4 years (2). In contrast, a British study did not find any increase in psychiatric symptoms (2). Women with an abnormal finding in a cervical smear test have reported increased anxiety after having been informed about the abnormality. However, sending an informative and reassuring leaflet to the subjects attenuates anxiety level to a notable degree (4). Advice to give up smoking is probably the most important health education message that can and should
be promulgated in contemporary societies. Two serious adverse effects must be borne in mind, however. First, smokers with an earlier history of major depression are likely to become depressed when trying to give up smoking and are therefore likely to start smoking again (5). Secondly, giving up smoking for a longer period, lasting for at least 1 year, may be followed by weight gain. On average, the weight gain within a period of about 10 years (adjusted for ageing, baseline Quetelet index and physical activity) has been found to be not more than about 3 kg for males and 4 kg for females. However, about 10% of the males and 13% of the females put on more than 13 kg (6). The above examples clearly show that specific screening and health education programmes may have notable adverse effects in healthy persons. In addition to this, doctors may sometimes abuse health education by definitely attributing the cause of the illness of their patient to some known risk factor, even if the association between the risk factor and disease remains unproven or unlikely. A story by Maranz (7) is illustrative. His friend Neil quite unexpectedly had an acute myocardial infarction at the age of 33 years. Neil had previously been in excellent health, except for a ‘borderline high blood pressure’ at college. During the last 2 years before the attack he had been normotensive and without any medication. He never smoked, his weight was 5% above the ideal, his cholesterol level 5.33 mmol/l and blood pressure 120180 mmHg 1 week before the infarction. The treating physician attributed the infarction to lack of exercise. Maranz suggests that doctors have a need to find a cause for everything, perhaps to alleviate their job stress by adopting a simplified, deterministic view of life (7). Such a way of reasoning may, if not based on facts, lead to a ‘blame the victim’ attitude, hurting the patient and his or her relationship with the physician. The adverse effects of being told of an illness have not infrequently been referred to as labelling or stigmatization. It seems useful, however, to make a distinction between the individual’s immediate reactions to the perception of being ill and labelling. The studies discussed above perhaps reflect more the immediate than the later reactions. Later reactions may also be amplified because of labelling. Labelling theory, or more appropriately the societal reaction perspective, argues that primariIy deviations from normal functioning have smaller effects on the individual than the societal reactions - or expectations of such reactions - that follow. The latter may bring about marked change in behaviour, often reinforcing behaviour patterns commonly held as typical for the
Ann Med Downloaded from informahealthcare.com by McMaster University on 12/29/14 For personal use only.
426
Poikolainen
deviant role in question (8). The sick role is always more difficult to accept than being healthy. It is likely to become especially difficult if the disease in question, say nicotinism, obesity, alcoholism or AIDS, is considered to be induced by the patient’s own behaviour and thus morally condemnable. Societal attitudes may have a great influence on the degree of psychic discomfort related to these diseases. The above is not to say that screening and health education should be diminished or stopped. Pfimum non nocere is an unrealistic principle. We have to accept that any medical intervention may entail adverse effects in addition to benefits. The risk of possible adverse effects of screening and health education is a risk we have to consider in relation to the benefits of these interventions. When intervening, we may best serve our patients by being aware of adverse effects and of the fact that these effects may be greatly reduced by tactful, emphatic behaviour, avoiding unnecessary moralism. Kari Poikolainen, Dr. Med. Sci. National Public Health Institute Mannerheimintie 166 SF-00300 Helsinki Finland
References 1. Bergman AB, Stamm SJ. The morbidity of cardiac non-
disease in schoolchildren. N f n g l J Med 1967;276:1008-13. 2. Alderman MH, Lamport B. Labelling of hypertensives: a review of the data. J Clin fpidemiol 1990;43:195-200. 3. Kidson MA. Personality and hypertension. J Psychosom Res
1973;17:35-41. 4. Wilklnson C, Jones JM, McBride J. Anxiety caused by abnormal result of cervical smear test: a controlled trial. Br Med J 1990;300: 440. 5. Covey LS, Glassman AH, Stetner F. Depression and depressive symptoms in smoking cessation. Comp Psychiatry 1990;31:350-4. 6. Williamson DF,Madans J, Anda RF, Kleinman JC, Giovino GA, Byers T. Smoking cessation and severity of weight gain in a national cohort. N Engl J Med 1991 ; 324:739-45. 7. Maranz PR. Blaming the victim: the negative consequence of preventive medicine. Am J Public Health 1990; 80:
1 186-7. 8. Clare A. Psychiatry in dissent: controversial issues in thought and practice, 2nd edn. London: Tavistock, 1980.
Ann Med Downloaded from informahealthcare.com by McMaster University on 12/29/14 For personal use only.
Doing Good, Doing Harm: Adverse Effects of Screening and Health Education in Perspective Primum non nocere, says an ancient principle of medicine. In practice, respect for not doing harm cannot be absolute. Rather, we should search for an optimal balance between the benefits and harms of medical interventions. Reaching this balance is often extremely difficult in patients with severe, debilitating diseases. In contrast, screening and health education are often thought of as unproblematic in this respect. Nonetheless, they also can bring about adverse effects. People identified as positive by a screening test, or patients learning during a medical examination that they have an abnormality of some kind often become physically distressed because of the awareness of having a disease. As a consequence, they may change their behaviour dramatically. Alarm after a positive screening test is a natural reaction and may be positive if it increases the interest in taking care of one’s health. However, unnecessary problems are brought about by false positive test results. Adverse effects have been reported for screening programmes for several diseases. An early example is the restriction of schoolchildren’s activity due to innocent cardiac murmurs in the 1960s also known as ‘cardiac nondisease’. In Seattle, 93 children out of 20,500 were found to have been told that they either had acute rheumatic fever or something wrong with their heart. Of these, 18 had clinically verified heart disease while 75 had not. Among the latter, 30 children had restricted their activities because of putative heart disease. Most of the unnecessary restriction was due to the physician’s advice. The authors stressed the importance of the rehabilitation of ‘nondiseased’ children and suggested that the benefits of this might far outweigh fhe results of mass disease screening programmes (1). In the 1950%headaches were found to become more prevalent in hypertensives after they become aware of their condition (2). Several studies found that the awareness of being hypertensive was followed by increased absenteeism from work (2),emotional lability, anxiousness, depression, somatic discomfort, and insecurity, suggesting neurosis (3). A Canadian study reported increased absenteeism from work for as long as 4 years (2). In contrast, a British study did not find any increase in psychiatric symptoms (2). Women with an abnormal finding in a cervical smear test have reported increased anxiety after having been informed about the abnormality. However, sending an informative and reassuring leaflet to the subjects attenuates anxiety level to a notable degree (4). Advice to give up smoking is probably the most important health education message that can and should
be promulgated in contemporary societies. Two serious adverse effects must be borne in mind, however. First, smokers with an earlier history of major depression are likely to become depressed when trying to give up smoking and are therefore likely to start smoking again (5). Secondly, giving up smoking for a longer period, lasting for at least 1 year, may be followed by weight gain. On average, the weight gain within a period of about 10 years (adjusted for ageing, baseline Quetelet index and physical activity) has been found to be not more than about 3 kg for males and 4 kg for females. However, about 10% of the males and 13% of the females put on more than 13 kg (6). The above examples clearly show that specific screening and health education programmes may have notable adverse effects in healthy persons. In addition to this, doctors may sometimes abuse health education by definitely attributing the cause of the illness of their patient to some known risk factor, even if the association between the risk factor and disease remains unproven or unlikely. A story by Maranz (7) is illustrative. His friend Neil quite unexpectedly had an acute myocardial infarction at the age of 33 years. Neil had previously been in excellent health, except for a ‘borderline high blood pressure’ at college. During the last 2 years before the attack he had been normotensive and without any medication. He never smoked, his weight was 5% above the ideal, his cholesterol level 5.33 mmol/l and blood pressure 120180 mmHg 1 week before the infarction. The treating physician attributed the infarction to lack of exercise. Maranz suggests that doctors have a need to find a cause for everything, perhaps to alleviate their job stress by adopting a simplified, deterministic view of life (7). Such a way of reasoning may, if not based on facts, lead to a ‘blame the victim’ attitude, hurting the patient and his or her relationship with the physician. The adverse effects of being told of an illness have not infrequently been referred to as labelling or stigmatization. It seems useful, however, to make a distinction between the individual’s immediate reactions to the perception of being ill and labelling. The studies discussed above perhaps reflect more the immediate than the later reactions. Later reactions may also be amplified because of labelling. Labelling theory, or more appropriately the societal reaction perspective, argues that primariIy deviations from normal functioning have smaller effects on the individual than the societal reactions - or expectations of such reactions - that follow. The latter may bring about marked change in behaviour, often reinforcing behaviour patterns commonly held as typical for the
Ann Med Downloaded from informahealthcare.com by McMaster University on 12/29/14 For personal use only.
426
Poikolainen
deviant role in question (8). The sick role is always more difficult to accept than being healthy. It is likely to become especially difficult if the disease in question, say nicotinism, obesity, alcoholism or AIDS, is considered to be induced by the patient’s own behaviour and thus morally condemnable. Societal attitudes may have a great influence on the degree of psychic discomfort related to these diseases. The above is not to say that screening and health education should be diminished or stopped. Pfimum non nocere is an unrealistic principle. We have to accept that any medical intervention may entail adverse effects in addition to benefits. The risk of possible adverse effects of screening and health education is a risk we have to consider in relation to the benefits of these interventions. When intervening, we may best serve our patients by being aware of adverse effects and of the fact that these effects may be greatly reduced by tactful, emphatic behaviour, avoiding unnecessary moralism. Kari Poikolainen, Dr. Med. Sci. National Public Health Institute Mannerheimintie 166 SF-00300 Helsinki Finland
References 1. Bergman AB, Stamm SJ. The morbidity of cardiac non-
disease in schoolchildren. N f n g l J Med 1967;276:1008-13. 2. Alderman MH, Lamport B. Labelling of hypertensives: a review of the data. J Clin fpidemiol 1990;43:195-200. 3. Kidson MA. Personality and hypertension. J Psychosom Res
1973;17:35-41. 4. Wilklnson C, Jones JM, McBride J. Anxiety caused by abnormal result of cervical smear test: a controlled trial. Br Med J 1990;300: 440. 5. Covey LS, Glassman AH, Stetner F. Depression and depressive symptoms in smoking cessation. Comp Psychiatry 1990;31:350-4. 6. Williamson DF,Madans J, Anda RF, Kleinman JC, Giovino GA, Byers T. Smoking cessation and severity of weight gain in a national cohort. N Engl J Med 1991 ; 324:739-45. 7. Maranz PR. Blaming the victim: the negative consequence of preventive medicine. Am J Public Health 1990; 80:
1 186-7. 8. Clare A. Psychiatry in dissent: controversial issues in thought and practice, 2nd edn. London: Tavistock, 1980.
