This study explored how HSPs targeted at individuals were conducted and promoted, how clinically appropriate HSP tests were, and the price range of packages. Most HSP providers, particularly private providers and social enterprises, included tests that were inappropriate for population screening. Apart from diabetes and cholesterol screening, there were otherwise no “standard” tests in HSPs. There was a diversity of test modalities and conditions being screened, which was reflected in the huge price range of HSPs from S$26 to S$10,561, with private providers having more expensive HSPs on offer. However, none of the cheapest packages (even for private providers) included all tests recommended under the ‘Screen for Life’ programme.
HSPs can be selected and booked with little to no medical guidance, even though more complex tests such as advanced imaging and endoscopic procedures such as nasoendoscopy were on offer. All providers in this study offered a medical assessment and a post-screening review to explain results. The websites presented HSPs positively as means of preventing complications through early detection and promoted providers’ services as being of good quality. They did not however discuss negative aspects of HSPs, such as direct risks from tests (e.g. risk of bleeding with a gastroscopy) or the possibility of false positives or false negatives.
Ethical issues arising from health screening packages
Despite the widespread availability of HSPs, they may not be in patients’ best interests and current practices raise many ethical questions. The inclusion of non-recommended tests may lead to an unfavourable risk–benefit ratio and the deluge of tests on offer can make it difficult for patients to be sufficiently apprised to make an informed decision. Furthermore, HSPs may result in a maldistribution of resources as scarce healthcare resources are funnelled towards screening which may not be beneficial or which exposes patients to unnecessary harms.
Beneficence and non-maleficence
Much of the debate and work on screening principles is based on the criteria Wilson and Jungner outlined in their seminal text ‘Principles and Practice of Screening for Disease’ [1, 2, 30, 31]. Although these criteria do not explicitly discuss ethical principles, beneficence and non-maleficence are clearly embedded within them. Many tests offered in the HSPs analysed are worryingly not aligned with screening principles. While it is unsurprising that all private providers and social enterprises offered non-recommended (Category 2 and 3) tests in their packages given the commercial interest to do so, it is concerning that 60% of the public providers sampled offered such tests, given the ethos of serving the public good that is generally associated with this sector. It does seem to suggest that the use of non-recommended tests in HSPs, which are more likely to be of minimal benefit and higher risk, may be pervasive in Singapore across all sectors.
Furthermore, some of the cheapest “basic” packages do not include screenings that are actually recommended. An example is cervical cancer screening (HPV DNA or Pap test depending on age). This recommended test was included in the cheapest packages by only two of the providers studied, and was sometimes offered as an add-on rather than included in the main package. A possible reason could be that the test requires additional skill, preparation and time to perform, whereas non-recommended tests (e.g. kidney function tests) can be done on the same sample collected for other recommended tests (e.g. fasting lipids). What this suggests is that HSPs may be designed more towards adding business value for providers rather than ensuring that patients get their recommended screenings.
Most providers analysed offered non-recommended screening (12 and 11 providers offered category 2 and 3 tests, respectively)—the use of tests lacking evidence for population screening increases the exposure of individuals to a litany of harms such as false positives or negatives, need for further investigations (that may be invasive), overdiagnosis and overtreatment, psychological distress and financial costs [3, 20, 32, 33]. However, none of the providers’ websites communicated these harms. Instead, these websites promoted the extensive use of these tests as a “comprehensive” assessment that empowers individuals to act on their health, which are not supported by beneficence and non-maleficence.
The lack of appropriate follow-up post-screening has also been surfaced in media reports, which have highlighted issues that could result from this, such as potential confusion over results or a missed opportunity for early treatment [8, 21]. This did not appear to be an issue for the HSPs analysed as all providers offered a medical consult post-screening. A possible reason could be that these packages were targeted at individuals and costed more compared to corporate packages (which may be discounted), and hence included more services such as a post-screening consult.
Autonomy and informed consent
Autonomy can be defined as “a notion that relates to how well a person is able to control her life according to her own decisions and actions” [3]. Informed consent, which is predicated on respect for autonomy, requires that a patient has adequate understanding of relevant and sufficient information in order to make a decision [28]. On the surface, it may appear that HSP providers in our sample respect or even promote autonomy by providing individuals information on their health status and personalised recommendations that they can act upon to improve health. However, a deeper dive on the HSP process shows that the converse is true. What would respect for autonomy look like for HSPs? Essentially, the individual should be provided balanced information about screening that would enable them to make an informed decision that is in their best interests, and the process to do so should be free from controlling influences such as manipulation.
While all websites in this study explained the benefits of screening and provided information on the process, there was virtually no information about potential harms. This absence of information is likely to be compounded by a lack of public understanding in Singapore about the benefits and risks of HSPs; an example is how financial blogs presented HSPs positively as a “comprehensive” health check without mention of potential harms [53, 57]. Such favourable views on HSPs by laypersons may be reinforced by silence from health authorities on HSPs. The Health Promotion Board, the statutory board responsible for health promotion in Singapore, briefly mentions that some tests may not be recommended and provides a link to the 2019 Report of the Screening Test Review Committee (which is intended for a medical audience) [67]. It does not however provide material pitched to the general public that enables them to better navigate HSPs and their appropriate utilisation.
Within the context of an information gap and the multitude of tests on offer (up to 71 tests for one provider analysed), it would be unreasonable to expect the average layperson to have adequate grasp of the topic to make an informed selection when experts themselves may not even agree if a particular test should be recommended [33]. Furthermore, even if detailed information on the pros and cons of each screening test were made available on providers’ websites, it does not necessarily mean that the individual’s decision-making process is free from manipulation. Because individual decision-making may be based on heuristics rather than relevant information, and because of the societal trust enjoyed by healthcare providers, laypersons may assume that providers are offering these tests because they are beneficial for health and proceed with them without actively seeking further information [27]. Additionally, healthcare providers may offer financial incentives to attract individuals to undergo a HSP, such as one provider in our study (Fullerton Health’s partnership with Mastercard, a credit card company) [65]. It is probable that such commercial inducements have an effect on individual screening decisions, which may not be purely based on “clinical” factors.
All the providers analysed allowed for package selection before a medical consult. This has similarities with issues faced in direct-to-consumer genetic testing in which consumers may be misled about the analytic and clinical validity of tests [68]. Arguably, doctors could discuss with patients on the risks and benefits of each test listed in the HSP during the consult before tests are administered; however, such an attempt (even if feasible) would not constitute informed consent—this may be perceived as “information dumping”, which inhibits understanding and thus undermines autonomy [3]. Permitting the selection of a HSP before a medical consult is also in conflict to a statement in the 2016 Singapore Medical Council Handbook on Medical Ethics—a resource which expounds on what the 2016 Ethical Code and Guidelines mean and provides advice on best practices—that doctors should “[t]ake a detailed history and perform a thorough clinical examination to detect health risks and plan appropriate screening tests” [69]. It also runs counter to providers’ claims that they provide “personalised” screening.
Our study showed that providers charged higher when more tests were performed, and there may be a potential conflict of interest for doctors between giving objective medical advice and encouraging more tests to improve earnings. Also, the most expensive package (S$10,561) analysed was more than 100 times the cost of recommended screenings under ‘Screen for Life’ (the most one may pay is S$80, inclusive of mammogram). In light of other studies showing the impact that financial incentives can have on medical care or advice rendered, it is reasonable to assume that doctors offering HSPs in our study may have strong extraneous interests that could influence information provided to patients that affects a patient’s ability to make an informed decision [22, 26].
Justice
This study found that HSP providers can charge patients hundreds to thousands of dollars for screening tests that may be unnecessary and potentially even harmful. Compared to the S$0 to S$5 fee that patients pay for recommended screenings and additional $25 to $75 for a mammogram under ‘Screen for Life’, HSPs may be pricier and much less “value-for-money” than the national screening programme. HSPs appear to allow scarce healthcare resources (e.g. advanced imaging) to be made available based on who is willing to pay rather than according to clinical need, potentially resulting in a maldistribution of resources and worsening inequities.
Patients who undergo HSPs and receive abnormal results may be advised on further testing and/or follow-up with a specialist. In some instances, this additional healthcare utilisation could have been avoided if the patient had not chosen a HSP to begin with. Often these abnormal findings are benign, but may set off a cascade of anxiety, additional investigations and follow-ups that may not be warranted in the first place [20]. An example is a thyroid nodule detected on ultrasound (which was offered by four of the providers in our study)—although majority of these lesions are benign, the small possibility that they are cancerous may necessitate regular follow-up to monitor their size [70]. Moreover, there is anecdotal evidence that some patients who underwent a HSP in the private sector and had an abnormal result will obtain a subsidised referral at the polyclinic to follow up with a specialist in the public sector. HSPs can potentially create additional demand for limited resources for care that may not be clinically necessary or cost-effective at the system level.
In our study, we identified five public hospitals and two social enterprises who offered HSPs. One possible reason for this is that profits earned from these packages may be used to off-set costs for other healthcare services that bring in less revenue. However, such reasoning is not ethically justifiable as these HSPs result in diversion of scarce resources away from other needs in the hospital and at a system level. Rather than using their resources to improve patient and population health through effective interventions, it is being used to stimulate unnecessary demand for healthcare testing through HSPs. For example, none of the public and social enterprise providers offered cervical and breast cancer screening in their cheapest packages even though these tests are recommended for population level screening.
Policy recommendations
The ethical issues discussed are complex and measures to address them would have to consider the health system at large. Health screening is not solely a population health intervention; it is a commercial activity in which the relationship between doctor and patient may also be characterised as one between buyer and seller. However, such a consumer-centric approach to screening can result in providers being incentivised to include more tests (which are often inappropriate) in HSPs. Instead, the guiding principles for this paper’s recommendations draw from the four principles approach to biomedical ethics: (1) persons should benefit from health screening, and harms should be minimised or avoided; (2) persons are adequately informed on the risks, benefits and alternatives of screening so as to respect their autonomy; (3) resources should be distributed according to need rather than ability to pay.
Additionally, policy recommendations should be feasible to implement and the intrusiveness of interventions should be justified by the public health benefits [29]. While it may be possible to legislate a ban on the use of non-recommended screening tests, such a blunt measure would be impractical and possibly excessive.
Based on the study findings, we propose recommendations to: (1) educate the public about screening and HSPs to reduce the information gap; (2) tighten regulations to minimise the use of tests not recommended for population screening, such as limiting advertisement of these tests; (3) limit the provision of screening services in hospitals to promote appropriate allocation of healthcare resources.
Public education on screening
First, there should be better public education on screening by health authorities such as the Health Promotion Board. As it would be impractical to require individuals to attend pre-screening consults for all tests, a more feasible approach would be improving the general public’s awareness. Current public engagement is focused on promoting the national screening programme and its benefits, with minimal guidance on non-recommended tests [5, 67]. More education should be provided on non-recommended testing, including potential risks. Not doing so may undermine national screening efforts as it can give rise to false perceptions that the ‘Screen for Life’ programme is incomplete or inadequate [53, 57]. We acknowledge that the provision of information may not translate into better public understanding on the benefits and risks of screening and HSPs as there can be many other factors such as systems and structural factors affecting an individual’s decision-making. However, there is presently no such information targeted to the general public from health authorities or advocacy groups in Singapore, and making available such information would be a necessary first step towards addressing the information asymmetry between providers and laypersons.
Tightening regulations on general population screening
Second, regulations on what type of tests can be offered for general population screening should be tightened and the impending regulation of health screening services under the Healthcare Services Act provides an opportunity to do so. These regulations should apply to all health screening (including corporate packages), not just standalone screening services. Providers should not be allowed to advertise or offer non-recommended tests as general screening at the first instance. Non-recommended screening may still be performed, but only after a medical consultation during which the patient is properly apprised of the benefits, risks and alternatives of such tests. A post-screening review with a healthcare professional should be offered, even for normal results, as patients may have queries related to the results or seek advice on preventive activities. Review for abnormal results should be done with a doctor to ensure that the patient is properly counselled and advised on them.
Limiting the provision of HSPs in hospitals
Lastly, the provision of HSPs in hospitals should be limited. Screening services should ideally be sited within primary care, where a regular provider oversees and coordinates a patient’s care. Majority of screening tests, including those in ‘Screen for Life’, do not require tertiary level provision and may create unnecessary demand for hospital resources. Such services may contribute to the misperception that hospital screenings are of a higher quality than those done in primary care, and may perpetuate inequities through its promotion of a model of care based on the ability to pay rather than on patients’ needs. For public hospitals, limiting its provision of HSP services could be done through the Ministry of Health’s ‘level of medical capability’ framework, which determines what level of service capabilities (and resourcing) each hospital should provide [71]. Medically indicated or opportunistic screenings may be allowed, but there should not be a clinical service dedicated to general health screening in the hospital. However, this framework does not apply to private hospitals for which the only way to implement this measure is through legislation—again, this is possibly excessive. Instead, better information on HSPs from health authorities and advertising restrictions as described earlier may be sufficiently effective to curb provider-induced demand in the non-public sector.
Strengths and limitations
The strength of this study is that it provides a detailed description of how HSPs are conducted in Singapore, how tests compare with evidence-based recommendations, how much patients are charged for such testing, and how HSPs are being promoted (including what messages they convey about screening) where such knowledge is currently lacking. While the scientific aspects of screening have been examined before, this is the first study that highlights the key ethical issues arising from the practice of HSPs and explores the implications of these issues on screening policy and practice in Singapore, adding another dimension of understanding to the literature on screening complexities.
The main limitation of this study was that purposive sampling was employed and it did not examine corporate HSPs. Only providers with readily available information on their websites were included in the study (this was generally more of an issue for corporate HSPs). While information on HSPs could have been sought from channels such as through phone calls or emails, this was not feasible during the conduct of the study due to logistical and time constraints. As such, the findings of this study may not be representative nor generalisable to all healthcare organisations providing HSPs. Additionally, the study did not include the perspectives of patients who underwent HSPs or doctors who provided such screening—these views would have been useful to better understand why patients went for such tests, what the perceived ethical issues are, and the implications for screening behaviour. Coding of messages communicated on the main page of the health screening section was done by a single coder, which may have resulted in failure to recognise other possible themes. Future research that takes a more representative sample, including corporate HSPs, would be useful. In addition, seeking provider and patient perceptions on HSPs and screening in general would contribute to better understanding of their decision-making process and allow for a more informed health screening policy.
https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-022-00798-5
