• and positive predictive value (proportion of positive test results that are actual cases). Serious social, political, and economic problems tend to arise when screening tests fail to identify most of the people with the disease (false negatives), or identify far more people than actually have the disease (false positives).
  • There should be adequate facilities for diagnosis and resources for treatment for all who are found to have the condition, as well as agreement as to who will treat them. Psychological trauma and social disruption are most likely to result when screening programs identify people with a disease but fail to provide treatment.
  • The test and possible interventions should be acceptable to the affected population. For instance, a screening program that required a spinal tap of all participants, or had pregnancy termination as the only option, might not be acceptable to some groups. Programs in which there are concerns about the use of patient information or even the primary motives (using the test as a means of discrimination designed to deny civil rights, for instance) might also be judged unacceptable.
  • The cost of case finding, diagnosis, and treatment or intervention should be economically balanced in relation to the medical cost savings that might result from the screening program. Screening programs need not be cost-saving, but their costs must be reasonable in relation to the anticipated benefits, and to other opportunities for public health programs.

Various legal and ethical principles should also apply to public health screening programs (Faden et al., 1991). As a general principle, the least burdensome approach (from a legal and ethical viewpoint) that meets public health goals should always be preferred.

Programs must conform, first of all, to the requirements of the United States and state constitutions, common law, and statutory provisions. Targeted screening programs, for instance, must avoid problems of denial of equal protection inherent in focusing upon particular groups for testing. Moreover, the means to achieve otherwise acceptable social objectives must be narrowly tailored to avoid interference with the exercise of other important liberties, such as privacy. Screening programs must also comply with existing legal requirements concerning informed consent and confidentiality, duties to treat, and standards of professional negligence (Faden et al., 1991).

Moral considerations not protected by laws must also be taken into account. Three broad principles—beneficence, autonomy, and social justice—guide these considerations. Beneficence relates to the need to balance the benefits of public health measures (chiefly the protection from disease) against the harms (which could be physical or involve the loss of privacy or autonomy). Respect for autonomy emphasizes the importance of individual freedom and choice, both for political life and for personal decisions. Justice relates to the fair distribution of benefits and burdens of a public health program. None of these principles can be

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