Prostate Cancer Screening: Lessons from Plato on Justice and Communication

We probably spend too much time on prostate cancer screening on Sensible Medicine. I attribute that John and I both are in the demographic for which the USPSTF entertains prostate cancer screening and that we, albeit subtly, disagree on the issue. We covered the recent ERSPC publications in a few ways. John dissected the article. We discussed it on This Fortnight in Medicine. I wrote a piece on the ethics of prostate cancer screening.

Today, I am pleased to share another take on the issue. I do think this adds something to our discussion.

Adam Cifu

In the wake of the extended follow-up results of the European Study of Prostate Cancer Screening (ERSPC), an ethical debate arises on the approach to screening for prostate cancer. After 23 years of follow-up, the ERSPC confirmed that prostate-specific antigen (PSA) screening reduced prostate cancer mortality by 13%, preventing one prostate cancer-related death for every 456 men invited to be screened. However, this mortality benefit involved significant overdiagnosis, requiring 12 diagnoses to save one life, suggesting that 11 of those 12 cases may have faced treatment harms without a survival benefit. From an ethical perspective, this trade-off is salient because screening brings a healthy, asymptomatic man into the medical system, turning him into a patient.

The U.S. Preventive Services Task Force (USPSTF) recommends that all men aged 55 to 69 make an individualized choice about screening with their doctor, weighing the potential benefits and harms. The American Cancer Society (ACS) advises that high-risk individuals, such as black men, begin these discussions at age 45. At the core of these guidelines is shared decision-making, in which clinicians and patients make decisions by incorporating medical evidence about risks and benefits with the patient’s values. The question is whether these discussions are ethically just toward the patient.

Plato serves as a great reference for the ethical principle of justice.

In The Republic, Plato describes justice as a harmony achieved when each part of the soul and the city performs its proper function, guided by reason. Justice, therefore, depends not only on good intentions but on the correct use of knowledge. If reason is the governing principle of a just soul, then evidence, which is the reasoned understanding of benefit and harm, must be the governing principle of a just shared decision-making encounter. Yet, despite modern medicine’s evidence-based foundations, we often communicate in ways that fail to convey benefits and risks appropriately.

When recommending PSA screening, clinicians frequently use phrases such as “this test may prevent death from prostate cancer” or “there is a small risk of a false positive.” These qualitative descriptions obscure the quantitative information available to, and necessary for, patients to make informed decisions. Clinicians may soften numerical data to make it more palatable or to reduce perceived burden. The term “small risk” can represent probabilities ranging from 1 in 10 to 1 in 10,000. By replacing quantitative data with qualitative language when discussing PSA screening risks and benefits, clinicians deprive patients of essential knowledge for evaluating outcomes, thereby risking an injustice of knowledge, known as epistemic injustice.

Patients frequently misinterpret benefits and harms when clinical information is presented qualitatively instead of numerically. Evidence indicates that patient decision aids enhance knowledge, improve risk perception accuracy, and support choices aligned with individual values, without increasing decision regret. These findings suggest that many patients consent to interventions without fully understanding the implications. Acting justly requires clinicians to respect patients’ capacity for reasoning by providing information in a format that enables genuine evaluation of potential benefits and harms.

Philosopher Miranda Fricker introduced the concept of epistemic injustice, defined as the unfair treatment of individuals as knowers. In medicine, epistemic injustice arises when patients are denied access to the same epistemic resources as clinicians, such as data, probabilities, and reasoning. When clinicians possess a quantitative understanding, while patients receive only qualitative information, disparities emerge not only in knowledge but also in power.

This imbalance recalls the dialogue between Socrates and Thrasymachus in The Republic. Thrasymachus declares that “justice is the advantage of the stronger,” a claim that uncomfortably describes the shared decision-making model for prostate cancer screening. The clinician, armed with expertise, defines what counts as a “small risk” or a “meaningful benefit.” The patient, dependent on this interpretation, must trust rather than deliberate. Justice, for Plato, arises only when reason governs, not strength or authority. In the clinical context, reason manifests as evidence communicated transparently.

Plato’s tripartite soul, which comprises reason, spirit, and appetite, serves as an analogy for the dynamics of modern medical shared decision-making. The clinician’s role aligns with reason, guiding the spirited and appetitive elements, such as emotion, hope, and fear, toward balanced action. When clinicians rely on qualitative framing, rhetoric, or authority rather than quantitative data, they abdicate their rational role. This shift allows emotion or convenience to dominate, resulting in an imbalance of the soul. Plato maintains that justice is realized when each part fulfills its proper function. Accordingly, the just clinician must fulfill the epistemic role by providing evidence transparently.

The consequences of qualitative communication go beyond misunderstanding. They distort patient autonomy. Autonomy, a core principle of medical ethics, assumes that patients have sufficient information to make decisions. In this sense, information should be presented in a way that allows for comparison and contrast, contextualization, and deliberation.

Additionally, qualitative communication tends to reinforce existing social and educational hierarchies. Patients with lower literacy or educational attainment are more likely to receive simplified explanations, thereby exacerbating disparities in shared decision-making. When reason is withheld, medicine moves from the pursuit of justice to the practice of persuasion.

What would a Platonic model of medical communication look like? Justice in clinical care requires a balance between knowledge, trust, patient autonomy, beneficence, non-maleficence, transparency, and respect. The clinician’s task is not to impose a decision, but to support reasoning and understanding. This requires communicating evidence numerically, contextualizing probabilities, and openly acknowledging uncertainty. For example:

Over about 20 years, PSA screening lowers the chance of dying from prostate cancer from about 16 in 1,000 men to about 14 in 1,000 men. That means that for roughly every 456 men invited to screening, one prostate cancer death is prevented, but about 12 men are diagnosed with prostate cancer to achieve that benefit. A positive screening result can also lead to additional testing, such as biopsies and imaging, and to treatments that carry their own risks. Overall, there is insufficient evidence that this extends lifespan.

Such a statement recognizes the patient as a rational participant in the shared decision-making process rather than a passive recipient of medical authority.

Plato’s insight remains relevant. In medicine, justice requires that patients possess both the understanding and the means to reason about their care. Overly simplified communication regarding risks and benefits undermines this equality, whereas clear, quantitative information enables patients to deliberate meaningfully and make informed decisions. By conveying evidence transparently, clinicians uphold justice, respect patient autonomy, and ensure that reason, rather than appetite or spirit, governs the shared decision-making process.

Owen Stratton is a third-year medical student at Wayne State University School of Medicine with plans to pursue a career in pathology. He is interested in understanding why we do what we do in medicine through critical appraisal, with a specific focus on screening and clinical trial methodology.