AMA Journal of Ethics^®

Abstract

Cancer is the second leading cause of death globally. Death rates from cancer reflect global inequality; approximately 70% of deaths from cancers occur in low- and middle-income countries (LMICs). Due to high costs of cancer treatment and limited access to resources, these countries are unable to use treatment as a primary means for reducing cancer burden. Thus, redirecting focus from treatment to prevention in LMICs and considering prevention as a global public health imperative are critical. The AMA Code of Medical Ethics and policies can guide efforts to promote and support cancer prevention in LMICs.

Global Burden of Cancer Inequality

Cancer is the leading cause of death globally, accounting for about 1 in every 6 deaths.¹ Deaths from cancer reflect global inequality, as approximately 70% of deaths from cancer occur in low- and middle-income countries (LMICs).¹ Increasing and already-high costs of cancer treatment, combined with a lack of access to resources, contribute to the highly concentrated burden of this disease in LMICs. These and other factors make it impossible for LMICs to use treatment as the primary means of reducing the cancer burden. Thus, shifting the focus from treatment to prevention in LMICs is critical to furthering this goal. Between 30% and 50% of cancers are preventable, but prioritizing prevention in these countries presents its own set of unique challenges.¹ The American Medical Association (AMA) Code of Medical Ethics offers guidance on disease prevention and health promotion that is applicable to addressing cancer in LMICs.

Preventive Medicine

Preventive medicine aims to protect, promote, and maintain the health of individuals, communities, and populations by taking steps to avert, rather than respond to, disease or sickness. The AMA is clear in its support of preventive medicine and of cancer prevention in particular. AMA Policy H-425.997, “Preventive Services,” states: “Our AMA encourages the development of policies and mechanisms to assure the continuity, coordination and continuous availability of patient care, including professional preventive care and early-detection screening services.”²

The AMA is clear in its support of preventive medicine and of cancer prevention in particular. 

Preventive medicine practice in LMICs presents unique challenges, however. AMA policies recommend that physicians and other health professionals become sufficiently familiarized with the country (or countries) in which the preventive services will be offered. AMA Policy H-425.984, “Clinical Preventive Services,” states: “Practicing physicians should become familiar with authoritative clinical preventive services guidelines and routinely implement them as appropriate to the age, gender, and individual risk/environmental factors applicable to the patients in the practice at every opportunity.”³ Similarly, AMA Policy H-425.986, “Challenges in Preventive Medicine,” states: “In concert with other groups, physicians should study local community needs, define appropriate public health objectives, and work toward achieving public health goals for the community.”⁴ Thus, in piloting programs to support cancer prevention in LMICs that are responsive to community needs, following Opinion 8.5, “Disparities in Health Care,” physicians should “cultivate effective communication and trust by seeking to better understand factors that can influence patients’ health care decisions, such as cultural traditions, health beliefs and health literacy, language or other barriers to communication and fears or misperceptions about the health care system.”⁵

In addition, the AMA Code states that preventive services being considered should be supported by evidence of improved outcomes or quality of life and should be cost effective.² Since studies do indeed show that services that help to prevent cancer improve both outcomes and quality of life,¹ developing and implementing cancer prevention services in LMICs that are cost effective is crucial to reducing premature cancer mortality.¹ To further these efforts, physicians should “support research that examines health care disparities, including research on unique health needs of all genders, ethnic groups, and disadvantaged populations, and on developing quality measures and resources to help reduce disparities.”⁵

Health Promotion

Supporting cancer prevention efforts everywhere, and especially in LMICs, is a duty of everyone in health care. Opinion 8.11, “Health Promotion and Preventive Care,” emphasizes and expands on this idea by stating:

Medicine and public health share an ethical foundation stemming from the essential and direct role that health plays in human flourishing. While a physician’s role tends to focus on diagnosing and treating illness once it occurs, physicians also have a professional commitment to prevent disease and promote health and well-being for their patients and the community…. Health promotion should be a collaborative, patient-centered process that promotes trust and recognizes patients’ self-directed roles and responsibilities in maintaining health.⁶

Opinion 8.11 offers more specific guidance for physicians. It asserts that individual physicians should:

(a) Keep current with preventive care guidelines that apply to their patients and ensure that the interventions they recommend are well supported by the best available evidence.
(b) Educate patients about relevant modifiable risk factors.
(c) Recommend and encourage patients to have appropriate vaccinations and screenings.
(d) Encourage an open dialogue regarding circumstances that may make it difficult to manage chronic conditions or maintain a healthy lifestyle, such as transportation, work and home environments, and social support systems.
(e) Collaborate with the patient to develop recommendations that are most likely to be effective.
(f) When appropriate, delegate health promotion activities to other professionals or other resources available in the community who can help counsel and educate patients.
(g) Consider the health of the community when treating their own patients and identify and notify public health authorities if and when they notice patterns in patient health that may indicate a health risk for others.
(h) Recognize that modeling health behaviors can help patients make changes in their own lives.⁶

Additionally, it states that, collectively, physicians should:

(i) Promote training in health promotion and disease prevention during medical school, residency and in continuing medical education.
(j) Advocate for healthier schools, workplaces and communities.
(k) Create or promote healthier work and training environments for physicians.
(l) Advocate for community resources designed to promote health and provide access to preventive services.
(m) Support research to improve the evidence for disease prevention and health promotion.⁶

The selections from the AMA Code featured here speak broadly to preventive medicine and health promotion and offer guidance on responding to ethical challenges associated specifically with cancer prevention in LMICs.