Introduction Approaches to Screening 26 38 50 53 50 53 39 41 27 32 16 37 Informed Choice in Screening 28 15 24 There has been no research to describe or evaluate the impact of an informed choice policy in screening. One possible impact is that it will reduce uptake of the screening programme with a greater reduction in some groups, for example those who are more socially deprived and already have lower participation in screening. Such a decline in the uptake of screening could be evaluated negatively as contributing to a decline in the overall health of the population or positively as reflecting an increase in the autonomy of the individual. This paper seeks to describe and evaluate the possible impact of an informed choice policy in screening. Explaining Screening Uptake 20 29 48 23 48 52 One such psychological characteristic might be time orientation. Psychologists suggest that people use information about the timeframe in which an event occurs to process information about the event and to make decisions. However, people’s responses to the specific timeframe in which an event might occur, vary. Individuals have preferences for certain timeframes which influence their information processing and evaluation of actions and the possible outcomes of those actions. These preferences are called time orientation. 55 42 22 25 34 42 42 42 18 42 18 56 33 47 Aims The first aim of this study is to describe the possible impact of an informed choice policy on screening uptake by exploring the relationships between social deprivation, present orientation and expectations of participation in screening. The second aim is to evaluate that impact from different ethical perspectives. Method Design A questionnaire-based descriptive survey. Sample A total of 300 participants was recruited. The sample was structured to reflect the English population in terms of age and sex with one third of the sample being drawn from each of the North, South and Midlands of England. Procedure Home-based interviews were conducted by a research agency. Questionnaires were completed by interviewers on behalf of participants. Materials 34 Expectations of participation in screening. 34 35 Time orientation. in submission 9 21 42 56 Social deprivation Possession of educational qualifications Home ownership (including having a mortgage). in preparation Analysis Statistical analyses were conducted using SPSS version 12. Associations between social deprivation, future and present time orientation and expectations of participation in diabetes screening were examined using Spearman’s rank correlations. Results 1 Table 1 Associations between expectations of participation in screening, social deprivation and present orientation (Spearman’s rho correlation)  Present orientation Future orientation Expectations of diabetes screening a −.245*** .067 .218*** Present orientation  −.301*** −.265*** Future orientation   .054 P a r n P r n P  r n P  r n P  1 1 1 1 Fig. 1 a b  in submission Summary The results of this study suggest that present orientation is associated with both social deprivation and with uptake of screening, such that present orientation partially accounts for the relationship between greater social deprivation and lower expectations of participation in screening. The results indicate that psychological factors can contribute to an explanatory framework of screening uptake. This framework suggests that there is an association between social deprivation and present orientation and that decisions about uptake of screening are influenced by the time orientation of those who are invited. This framework further suggests that making the more immediate possible harms of screening more salient, as would happen in an informed choice policy, could reduce uptake of screening in those who are more socially deprived. This framework can be used to identify and evaluate the possible impact of an informed choice policy in screening. Evaluation The Possible Impact of Informed Choices on Inequality 12 7 17 3 8 10 11 We should say at the start that our aims are limited and that we do not try, nor think it possible, to evaluate an informed choice policy fully in the space available. Our discussion is aimed at those who feel an initial ethical pull both toward reducing inequality and toward informed choice. Among those who feel this pull are the UK government, whose policies are explicitly designed to try to achieve both. Thus we do not aim to persuade those libertarians or elitists who oppose taxation-funded screening programs altogether. Nor do we intend the ethical claims we make to be applicable in all times and places. In aiming our discussion at those who are attracted both to equality and choice, we do not suggest that the nature of these values is at all obvious. Indeed, one of our major points will be that any evaluation of an informed choice depends on further specification of these values. It might well turn out, as these values are specified, that the dilemma between choice and equality is merely apparent and that a decision between them in the context of screening does not have to be made. After the ethical characterization of the choice and equality dilemma, we critique a public health and paternalistic approach to screening that is sceptical about the value of choice. Is There a Dilemma? As mentioned, it appears that there is a dilemma for those who value both choice and equality if an informed choice policy reduces the rate of screening of the most deprived without significantly reducing the rates for everybody else. It appears that the health of the most deprived would decline relative to others and thus inequality of health would increase. Whether there is actually a dilemma depends partly on what happens to screening rates in practice, but it also partly depends on the characterization of the ethical values, as we shall now show. 51 46 4 13 14 19 25 5 51 1 44 45 6 30 31 36 40 49 36 In the face of this sketch of various positions, it is clear that evaluating any inequality produced by an informed choice policy requires more detail about those effects. That inequality increases does not on its own justify opposing the policy. Suppose inequality increases because the most deprived stay the same, on whatever is the right metric for measuring people’s positions, but the position of others improves. Utilitarians and prioritarians should endorse the policy. Egalitarians might oppose it but also might not, depending on the other values they hold. Suppose the position of the most deprived goes down and others’ positions improve. Egalitarians and prioritarians would probably oppose it, although that might depend on how much the most deprived lose and how much others gain. Utilitarians will weigh up the gains and losses to see what maximizes welfare. In this section we have pointed out some of the complexities of evaluating the policy of informed choice even if we assume some initial ethical commitment to both choice and equality. In particular, we have shown that the initial statement of the dilemma between choice and equality is too crude, and that there might be no dilemma in the end. In describing the complexities we do not want to suggest that a rationally defensible overall evaluation is impossible, only that it is perhaps more difficult than one might think. In the next section, we continue the theme of complexity by pointing to the for a brisk paternalistic public health approach that says that if choice reduces health it must be bad. Informed Choice, Public Health, and Paternalism 54 38 2 38 24 1 5 43 A persuasive paternalistic argument must show that, given the possibility of an informed choice, the people would tend to choose against their interests and that this would justify denying them the choice. We have not shown that no such argument could be made, but we have tried to show the severity of the difficulties that face it. Conclusions This paper has shown how psychological research can contribute to assessing the possible impact of an informed choice policy on screening uptake. It suggests that an informed choice policy could lead to a decrease in uptake of screening amongst those who are most socially deprived, resulting in decreases in the physical health of this group. From a public health perspective any decrease in physical health is a matter of concern, particularly if that decrease is greater in those who are more socially deprived. From an informed choice perspective such a decrease in uptake could be interpreted as indicating that people are making autonomous choices based not only on good knowledge, but also in line with their own values. Those who are more socially deprived are more present orientated. They therefore value actions that have positive outcomes immediately and thus, once they understand that the benefits of screening are not immediate, may be less likely to participate in the screening programme. These results have been evaluated from different philosophical perspectives on health inequality and on choice. This evaluation has not attempted to provide a definitive assessment of whether the introduction of an informed choice policy in screening can be justified in the light of the likely impact on physical health inequalities outcomes across the population. Rather, the evaluation has sought to describe the way in which philosophical approaches to choice and to health inequality can be used to inform further discussions about choosing an informed choice approach to screening over a public health approach.