Challenges of informed choice in organised screening.

CONTEXT: Despite much research on informed choice and the individuals' autonomy in organised medical screening, little is known about the individuals' decision-making process as expressed in their own words. OBJECTIVES: To explore the decision-making process among women invited to a mammography screening programme. SETTING: Women living in the counties of Sør- and Nord-Trøndelag, Norway, invited to the first round of the Norwegian Breast Cancer Screening Program (NBCSP) in 2003. METHODS: Qualitative methods based on eight semistructured focus-group interviews with a total of 69 women aged 50-69 years. RESULTS: The decision to attend mammography screening was not based on the information in the invitation letter and leaflet provided by the NBCSP. They perceived the invitation letter with a prescheduled appointment as if a decision for mammography had already been made. This was experienced as an aid in overcoming the postponements that easily occur in daily lives. The invitation to mammography screening was embraced as an indication of a responsible welfare state, "like a mother taking care." CONCLUSION: In a welfare state where governmental institutions are trusted, mass screening for disease is acknowledged by screening participants as a valued expression of paternalism. Trust, gratitude, and convenience were more important factors than information about benefits, harms, and risks when the women made their decisions to attend screening. These elements should be included in the ethical debates on informed choice in preventive medicine.

Shoulder dystocia--malpractice or acceptable risk?

BACKGROUND: In 1988 a new patient insurance system was introduced in Norway. It was initially described as an 'objectified' system, similar to one based on the no-fault principle. Early doubts were raised about the system's status, as it contains rules stating that compensation will not be given if the medical intervention is adequate and the involved risk is acceptable. This study was undertaken to examine the practice of these rules. METHODS: An archival study was performed on the 41 shoulder dystocia cases that had been closed in the decade from 1988-1997. These cases were selected as shoulder dystocia was found to be the obstetrical event most often leading to a decision on acceptable risk. RESULTS: The most common injury in these cases was Erb's palsy, but fatalities and brain injuries were also observed. Compensation was given in nine cases, whereas it was denied due to an acceptable medical risk in the remaining cases. Indications of inconsistency among the reached decisions were found, and judged to be a result of differences of opinion between expert witnesses on the adequacy of the obstetrical practice. CONCLUSIONS: Doubts are raised as to whether similar decisions are reached in similar cases. Shoulder dystocia may be an acceptable risk in the sense that it is hard to predict and prevent. Whether the consequences of such a risk should be compensated, remains a political and economical issue. Present thinking leads to decisions that create a divide between the lucky unlucky and the plainly unlucky.

[The murder at Grünerløkken--a centenary]. / Drabet paa Grünerløkken--et hundreårsminne.

In December 1898, a five year old boy was found murdered and sexually abused at Grünerløkka in Oslo. The crime was reported to the police by a 19 year old boy, who soon after was detained and charged with the misdeed. In spring 1899 he was found guilty and sentenced to life imprisonment with hard labour. This article is based on a long and detailed forensic medical and psychiatric report from the investigation and trial, published in this Journal in 1899, and on the Oslo press coverage of the crime. It shows that much has changed during these 100 years regarding both the privacy of the victim, the accused and their families, and factors paid attention to in the psychiatric assessment of the accused.

[Risk as a concept and challenge in health care]. / Risiko som begrep og utfordring i helsevesenet.

There has been an epidemic in the use of the word risk since the 1960s. This has happened at a time when the focus of medicine is turning from the diseased to the healthy part of the population. The meaning of the word has changed in the course of this century. As a tool for legitimizing medical interventions in the healthy, it currently serves an important ideological function in the battle for public health. Risk assessment is not a question of knowledge versus belief, as illustrated by present controversies within the medical community. Early conceptions of information on risk as sufficient motive for changing behaviour seem naive in the light of psychological research. Better communication is possible through improved techniques, but these techniques do not, however, provide the answers to what is the best way to deal with the risks. Knowing about risk is not always beneficial, it may also lead to illness. Excessive diagnostics and treatment are other questionable effects. The primary negative focus of risk also raises the question of whether risk represents a blind alley on the road to health.

The risk epidemic in medical journals.

Searches in MEDLINE databases show a rapid increase in the number of articles with the term 'risk(s)' in the title and/or abstract in the period from 1967 to 1991. This trend is found in medical journals giving a general coverage of medicine and journals covering obstetrics and gynaecology in U.S.A., Britain and Scandinavia. The most rapid increase is, however, found in epidemiological journals. Comparisons of the developments in the occurrence of such terms as risk, hazard, danger and uncertainty show that the increasing frequency of the term risk in the medical literature can not be explained as a change in terminology alone. It is hypothesized that the ongoing trend, which resembles an epidemic, is a result of developments in science and technology, that has changed our beliefs about the locus of control from factors outside human control to factors inside our control. The origins of the epidemic may be traced to the development of such disciplines as probability statistics, increased focus on risk management and health promotion, with recent developments in computer technology as the factor responsible for the escalation seen in the past decade. With the cultural selection of risks in mind, the social construction of risk is discussed. Potentially harmful effects of such an epidemic are discussed, exemplified through controversies over current epidemiological risk construction and strategies for coronary risk reduction. It is finally argued that the risk epidemic reflects the social constructions of a particular culture at a particular time in history.

[Medical technical equipment--not so dangerous after all?]. / Medisinsk-teknisk utstyr--ikke så farlig likevel?

More than a decade has passed since the Ofstad committee presented its report on "Control of medical devices". The committee assumed that the use of medical devices constituted a major safety problem in the Norwegian health care system. The frequency of device-related injuries to patients was expected to be high, especially since the amount of non-recorded injuries was expected to be large. During the period since the publication of the report, several medical device reporting systems have been established, and special injury committees have been formed in some hospitals. Several "ombudsmen" for patients now exist, and both a patients' association and an insurance system for compensation to injured patients have been established. Despite this, we still do not know the total number of medical device-related injuries to patients in Norway. However, the existing records do show that device-related injuries to patients are not as abundant as the Ofstad committee feared.

General practitioners' attitudes to oestrogen prescription in the menopause: a national survey in Norway.

A questionnaire was mailed to a random sample of approximately 10% of Norwegian general practitioners (GPs) in order to investigate attitudes to the prescription of hormone replacement therapy (HRT) in menopausal women. Nine short case histories were presented, and the GPs indicated their attitude to oestrogen prescription in each case on a five-step scale. Each case history contained four items that were systematically varied so that the effect of each could be investigated by comparing the answers from case to case. 251 GPs (74%) responded to the questionnaire. The answers indicated restrained attitudes towards prescription of HRT. Smoking and a family history of cardiovascular disease were regarded as contraindications. Angina pectoris was considered a contraindication for local oestrogen application in elderly women with urogenital complaints.

[Consequences of diagnostics with magnetic tomography]. / Konsekvenser av diagnostikk med magnettomografi.

Physicians referring patients to examinations by magnetic resonance tomography (MT) were asked to answer almost identical questionnaires before and after the examination. The questions referred to diagnosis and planned patient management. Impact of MT was measured by examining the changes in patient diagnoses and planned management after the MT scans. In 33% of the group (400 patients) the main diagnosis (four digit ICD-9 code) changed after MT. Diagnostic security was better for 43%, and further diagnostic follow-up changed for 56%, surgery for 20% and radiation therapy for 11%. MT was assumed to have had real consequences for 33% of the patients in terms of significant changes in the doctors planned management or in his concept of the disease. In a follow-up study 1.5-2 years after MT, 64% of the referring doctors were of the opinion that the MT scan had had consequences for the patient and they placed the emphasis on less active patient follow-up after MT.