Good health checks according to the general public; expectations and criteria: a focus group study.

BACKGROUND: Health checks or health screenings identify (risk factors for) disease in people without a specific medical indication. So far, the perspective of (potential) health check users has remained underexposed in discussions about the ethics and regulation of health checks. METHODS: In 2017, we conducted a qualitative study with lay people from the Netherlands (four focus groups). We asked what participants consider characteristics of good and bad health checks, and whether they saw a role for the Dutch government. RESULTS: Participants consider a good predictive value the most important characteristic of a good health check. Information before, during and after the test, knowledgeable and reliable providers, tests for treatable (risk factors for) disease, respect for privacy, no unnecessary health risks and accessibility are also mentioned as criteria for good health checks. Participants make many assumptions about health check offers. They assume health checks provide certainty about the presence or absence of disease, that health checks offer opportunities for health benefits and that the privacy of health check data is guaranteed. In their choice for provider and test they tend to rely more on heuristics than information. Participants trust physicians to put the interest of potential health check users first and expect the Dutch government to intervene if providers other than physicians failed to do so by offering tests with a low predictive value, or tests that may harm people, or by infringing the privacy of users. CONCLUSIONS: Assumptions of participants are not always justified, but they may influence the choice to participate. This is problematic because choices for checks with a low predictive value that do not provide health benefits may create uncertainty and may cause harm to health; an outcome diametrically opposite to the one intended. Also, this may impair the relationship of trust with physicians and the Dutch government. To further and protect autonomous choice and to maintain trust, we recommend the following measures to timely adjust false expectations: advertisements that give an accurate impression of health check offers, and the installation of a quality mark.

What is a good health check? An interview study of health check providers' views and practices.

BACKGROUND: Health checks identify (risk factors for) disease in people without symptoms. They may be offered by the government through population screenings and by other providers to individual users as 'personal health checks'. Health check providers' perspective of 'good' health checks may further the debate on the ethical evaluation and possible regulation of these personal health checks. METHODS: In 2015, we interviewed twenty Dutch health check providers on criteria for 'good' health checks, and the role these criteria play in their practices. RESULTS: Providers unanimously formulate a number of minimal criteria: Checks must focus on (risk factors for) treatable/preventable disease; Tests must be reliable and clinically valid; Participation must be informed and voluntary; Checks should provide more benefits than harms; Governmental screenings should be cost-effective. Aspirational criteria mentioned were: Follow-up care should be provided; Providers should be skilled and experienced professionals that put the benefit of (potential) users first; Providers should take time and attention. Some criteria were contested: People should be free to test on any (risk factor for) disease; Health checks should only be performed in people at high risk for disease that are likely to implement health advice; Follow up care of privately funded tests should not drain on collective resources. Providers do not always fulfil their own criteria. Their reasons reveal conflicts between criteria, conflicts between criteria and other ethical values, and point to components in the (Dutch) organisation of health care that hinder an ethical provision of health checks. Moreover, providers consider informed consent a criterion that is hard to establish in practice. CONCLUSIONS: According to providers, personal health checks should meet the same criteria as population screenings, with the exception of cost-effectiveness. Providers do not always fulfil their own criteria. Results indicate that in thinking about the ethics of health checks potential conflicts between criteria and underlying values should be explicated, guidance in weighing of criteria should be provided and the larger context should be taken into account: other actors than providers need to take up responsibility, and ideally benefits and harms of health checks should be weighed against other measures targeting (risk factors for) disease.

[Wish-fulfilling medicine in Dutch practice. Have physicians become salesmen?]. / Wensgeneeskunde: worden dokters nu verkopers?

Wish-fulfilling medicine - the use of medical technology for the prima facie non-medical wish of the patient - occurs in practice, both in and outside the Netherlands. In a recent study both GPs and plastic surgeons recalled occasions when they had fulfilled patient's non-medical wish, sometimes against their own better judgement. The question is whether this is turning physicians into salesmen? The central values of medical professional ethics, namely autonomy, non-maleficence, beneficence, and justice still appear to play a central role. Neither physicians nor lay persons view physicians as salesmen. However, it appears that the balance between the importance attached to a well-considered wish of a patient and the associated risks and harms is shifting. Thus, a physician may well perform wish-fulfilling requests and still remain a good physician. However, there is certainly room for refusal.

Wish-fulfilling medicine in practice: the opinions and arguments of lay people.

BACKGROUND: Wish-fulfilling medicine appears to be on the rise. It can be defined as 'doctors and other health professionals using medical means (medical technology, drugs, and so on) in a medical setting to fulfil the explicitly stated, prima facie non-medical wish of a patient'. Some instances of wish fulfilling medicine can be understood as 'human enhancements'. AIM: The aim of this study is to map the normative opinions and arguments of lay people about wish-fulfilling medicine. METHODS: We conducted a qualitative study with lay people (five focus groups). We asked their opinions about five cases and the arguments for these opinions. Furthermore, we enquired about the role of the medical profession and the treating physician, and whether the participants saw a role for the government. RESULTS: The opinions and arguments used varied according to the example discussed. For instance, increased familiarity with a procedure like breast enhancement seems to garner more acceptance for that procedure, whereas completely new examples were considered less acceptable. Various different arguments were raised in focus groups; these included: people should be allowed to make up their own minds about this (autonomy); payment of the treatment; and concerns about risks. DISCUSSION: An ethical analysis of the emerging practice of wish-fulfilling medicine should take the normative views of all parties involved into account. Thus, it is important to establish what lay people think about wish-fulfilling medicine and in particular their arguments.

Wish-fulfilling medicine in practice: a qualitative study of physician arguments.

There has been a move in medicine towards patient-centred care, leading to more demands from patients for particular therapies and treatments, and for wish-fulfilling medicine: the use of medical services according to the patient's wishes to enhance their subjective functioning, appearance or health. In contrast to conventional medicine, this use of medical services is not needed from a medical point of view. Boundaries in wish-fulfilling medicine are partly set by a physician's decision to fulfil or decline a patient's wish in practice. In order to develop a better understanding of how wish-fulfilling medicine occurs in practice in The Netherlands, a qualitative study (15 semistructured interviews and 1 focus group) was undertaken. The aim was to investigate the range and kind of arguments used by general practitioners and plastic surgeons in wish-fulfilling medicine. These groups represent the public funded realm of medicine as well as privately paid for services. Moreover, GPs and plastic surgeons can both be approached directly by patients in The Netherlands. The physicians studied raised many arguments that were expected: they used patient autonomy, risks and benefits, normality and justice to limit wish-fulfilling medicine. In addition, arguments new to this debate were uncovered, which were frequently used to justify compliance with a patient's request. Such arguments seem familiar from conventional medicine, including empathy, the patient-doctor relationship and reassurance. Moreover, certain arguments that play a significant role in the literature on wish-fulfilling medicine and enhancement were not mentioned, such as concepts of disease and the enhancement-treatment dichotomy and 'suspect norms'.