Overdiagnosis, ethics, and trolley problems: why factors other than outcomes matter-an essay

In February 2014, the non-governmental Swiss Medical Board recommended that mammography programmes in Switzerland may eventually be closed down because they might not deliver more benefits than harms. In the resulting uproar the board was accused of being "unethical." Controversy about mammography has persisted in the UK, US, Canada, and elsewhere, and disputes about overdiagnosis exist in prostate cancer, chronic kidney disease, attention-deficit/hyperactivity disorder (ADHD), and many other conditions. People concerned about overdiagnosis are compelled by evidence of harms outweighing benefits. But not everyone is equally compelled. This may be because of disagreements over the evidence, conflicts of interest, or cognitive biases. Another possible cause of disagreement is that some people may not think that benefits and harms are the most important consideration. This contrast, between people who think outcomes are what matters most and people who disagree, is central to the discipline of ethics. It is a crucial difference between utilitarian ethicists and non-consequentialist ethicists. Broadly, utilitarians think that, given several options, we should choose the one that produces the best overall outcome (the most utility among the whole group of affected people), ensuring that each person counts equally in the calculation. Non-consequentialists don't consider outcomes to be so important: other ethical concerns, such as rights, duties, or respect for people's dignity or autonomy, matter more.