Will PSA screening be an ethical tragedy in the future?

The New York Times ran a fascinating piece about a dusty old medical experiment that was brought back to life recently after one of its perpetrators — err, researchers, decided to come clean to a medical historian after having read the book The Immortal Life of Henrietta Lacks.

The unnamed confessor was a surgical resident in the 1950s under Dr. Perry Hudson, the man in charge of the experiment. Dr. Hudson (a urologist, still alive at age 96, and adamant that he did nothing wrong) had funding from many sources, including the National Institutes of Health.

The experiment involved recruiting “skid row” alcoholics from flop houses in the Bowery (NYC) and offering them “free medical care” for their participation. The researchers made incisions in the subjects’ nether parts and took wedge-shaped biopsies of their prostate glands. Only problem with this was that the men were not given full information about what would happen to them — their consent was coerced with false promises and not, as we like to say, informed.

The goal of the research was to learn how to diagnose and treat prostate cancer earlier in men — a worthy goal, to be sure, but handled in a very unethical manner.

The test subjects had their rectums perforated. Some got life-threatening infections. A third developed impotence, another third couldn’t control their urine after the biopsies.

Obviously the standards of the time were much different. But we would think that something like this could never happen after Nuremberg (wait! this was after Nuremberg). How could an American surgeon, so soon after the horrors of the Nazi doctors, use vulnerable men in dubious research — research that wasn’t designed well enough to include a control group?

The Times article assessing this not-too-distant past ends with three paragraphs that are particularly haunting, in light of the Pandora’s Box that is our current state of the art in prostate cancer diagnosis and treatment:

A federal panel of experts recommended in 2011 that men no longer get the P.S.A. blood test to screen for prostate cancer because clinical trials had found that the test’s benefits are uncertain and its risks — treatments that needlessly cause incontinence and impotence — are severe.

But many urologists believe screening saves lives, and the American Urological Association recommends that men consider starting it at age 55.

“Ethical tragedies are difficult to recognize in the present,” [the author] wrote. “Future observers may view the massive evidence-challenged expansion of our screen-and-treat paradigm in prostate cancer in the same way as we now view the Bowery series practices.”

I think we all need to believe that as problematic and thorny as this issue is, men today are more informed than those of previous generations. But we must do a better job of giving the full picture of all the risks of not only treatment, but screening, too.

John Schumann is an internal medicine physician who blogs at GlassHospital.

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  • Doctor Nick

    Because the “unfettered” “market” was doing such a fantastic job, right?

    • NormRx

      Did I say that the unfettered market was doing such a fantastic job? But, if I had to put my trust in the private market or a government run monopoly, I will put my trust in the private market. If I get hosed in the private market I have several recourse’s, I can change service providers, I can sue (this would be my last option since I believe most law suits are frivolous) and I can complain to the appropriate regulatory agency.

      When the same institution (the government) provides the services and the regulations governing those services and you are forbidden to sue, what recourse does the patient have? I have seen what government run health care is like when I was in the Air Force, and the VA isn’t any better.

  • Ed

    For years the science behind PSA testing has been questionable at best, the USPSTF finally recommends against, and the last major physician specialty to climb onboard are Urologists. Whatever happened to “First, do no harm” as the bedrock of medical ethics? And they wonder why we no longer trust them!

  • southerndoc1

    “Now we have the government totally taking over our health care.”

    Have United, Aetna, Cigna, Blue Cross et. al. gone out of existence, and I just didn’t notice it?

    • NormRx

      Of course they haven’t, but who now determines what coverage your policy must have and who determines what the cost of coverage will be? The insurance companies are merely administering the government run health care programs. The insurance companies have always been highly regulated by both the states and the federal government now the takeover is complete.

  • Dr. Drake Ramoray

    While this post is not intended to suggest no regulation of medications or medical procedures. See fatalities from using silicone from hardware stores for butt implants.

    http://detroit.cbslocal.com/2013/08/05/dangerous-butt-injections-a-growing-problem/

    I would have to say any semblance of “unfettered market” in healthcare ended on June 30th 1906 when Teddy Roosevelt signed the law that created the FDA.

  • drjoekosterich

    Whenever we thinks we are “sure” of something in medicine we always need to think again.

  • Victor Trismegistus Lyc-Vamp D

    Perhaps PSA is not that bad at that. Thre’s Free PSA, Total PSA, and F/T PSA. There’s also the possibility of building a PSA curve, instead of just taking single tests. And, of course, there’s individualized evaluation of a numeric value, taking into account several clinical data.

    To be sure, what does give me the creeps is that — in the times of Evidence-Based Medicine, high-res radiology, ultrasound and MRI — people are willing to consider, as sole evidence, the “tactile sensations” and other such subjective evidence that a — however well trained — urologist can obtain through digital examination. Really, is there nothing better available?

    No preconceived notions about that kind of examination, but that’s what gives me the creeps. Sometimes the patients are the victims of NO applied technology.

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