Journal Article

Ethics of overtreatment and undertreatment in older adults with cancer

Hshieh, Tammy T., Whitehead, Mary I., Abel, Gregory A., Perumal, Neha, Blackstone, Eric C., Mustian, Lewis, Revette, Anna C., Sanyal, Ameya, Uno, Hajime, Driver, Jane A., Dale, William, DuMontier, Clark, Roberts, Jane

2025

Overview

Background Over-/undertreatment are pervasive in older adults with cancer, and challenges arise in applying the principles of bioethics: beneficence, nonmaleficence, justice, and patient autonomy. The objective of this study was to determine whether these ethical principles relate to over-/undertreatment for older adults, and how tensions among the principles may contribute. Methods We conducted a modified Delphi study with 13 experts in biomedical ethics for iterative rounds of data collection. In the first round, we presented via electronic questionnaire our previously published definitions of over-/undertreatment in older adults with cancer. We then asked which ethical principles related to each definition, followed by how over-/undertreatment might arise from conflicts among different ethical principles. Consensus for each question was defined as ≥ 75% of experts answering “agree” or “strongly agree”. The second round consisted of a virtual discussion with nine of the panel experts led by a qualitative researcher to summarize round one results and review questions that did not reach consensus, followed by a second questionnaire including those questions. Findings Experts reached consensus that beneficence, non-maleficence, and autonomy were related to over-/undertreatment in older adults with cancer. Consensus was reached (92%) that overtreatment can occur when oncologists overemphasize beneficence valuing the potential benefit of cancer treatments, while underemphasizing non-maleficence with respect to treatment toxicities. Consensus was also reached (85%) that undertreatment reflects a lack of justice in equitable consideration of cancer treatments that could provide similar net benefits in older adults compared to younger adults. Lastly, consensus was reached that, in most cases, it is unethical to make a treatment recommendation without (1) formal assessment of patient frailty (e.g., via a geriatric assessment) or (2) the opportunity for the patient to share their values, goals, and preferences. Interpretation Our findings elucidate the ethical principles underpinning over- and undertreatment in older adults with cancer.

• Publisher: BioMed Central,BioMed Central Ltd,Springer Nature B.V,BMC
• Subject: Aged / Aged patients / Analysis / Beneficence / Bioethics / Cancer / Cancer therapies / Care and treatment / Consensus / Delphi Technique / Education / Ethical aspects / Ethics / Ethics, Medical / Female / Geriatric oncology / Health care disparities / Humans / Male / Medical ethics / Middle Aged / Neoplasms - therapy / Older people / Oncology / Overtreatment / Patients / Personal Autonomy / Philosophy / Philosophy of Medicine / Principles / Questionnaires / Social Justice / Surveys and Questionnaires / Theory of Medicine/Bioethics / Undertreatment