seen as consistently more important than the others, but the degree to which they are satisfied must be balanced in every instance (Faden et al., 1991).

Spectrum of Screening Programs

Although screening programs are commonly thought of as either voluntary or mandatory, there is in fact a continuum of approaches that can be taken. Faden and colleagues (1991) characterize five types of programs: (1) completely mandatory, (2) conditionally mandatory, (3) routine without notification, (4) routine with notification, and (5) non-directive patient choice.1

In a completely mandatory program, a government agency requires citizens to undergo a screening test and sanctions those who do not comply. In public health screening programs, either providers or patients can be compelled to take action and suffer the consequences of not doing so. In addition, mandatory programs differ in the degree to which they are enforced, and the nature of the sanction for not complying. Enforcement and sanctions typically vary according to the agency upon which the mandate falls. State health departments can more easily enforce a policy requiring hospitals to test individuals than one requiring individuals to be tested because hospitals are subject to regulation, receive government funding, and regularly report a variety of performance measures.

In a conditionally mandatory program, either government or a private institution makes access to a designated service or opportunity contingent upon participation in the screening program. A prenatal care provider, for instance, could require women to undergo certain tests as a condition of receiving prenatal care.

Individuals in a routine without notification program are routinely and automatically tested unless they expressly ask that the test not be done.

Participants in a routine with notification program are informed that a certain test is a standard part of prenatal care, and that they have the right to refuse before the testing is done. Most women will be tested unless they explicitly opt out. Written informed consent is not necessary, but providers might want to document patient refusals in order to protect themselves from malpractice liability.

In a non-directive patient choice program individuals are provided information about the test, and the choice about whether to be tested is left to them. Patients actively must choose to be tested, and if they do not opt to be tested, the default is that no testing will occur. This type of program is the model typically employed in the context of genetic counseling where it is labeled "non-directive counseling." This also is the model used by HIV anonymous test sites.

While routine with notification and routine without notification programs,


Faden and colleagues (1991) called the last option "voluntary," but the committee chose to call it "non-directive patient choice" to stress the more active role of the patient inherent in this type of program.

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